Patient Screening Form

A therapeudic partnership is key to getting to the root cause of chronic illness.

Fill out the two forms today for a free Zoom consultation.

PLEASE COMPLETE BOTH FORMS

Step 1 AND Step 2 must be completed before the Zoom consultation can be scheduled.

Potential patient’s name: *

Email *

Phone *

STEP 1

How did you hear about Trisha Howell and Smart Wellness® LLC? *

Assessing Commitment

What are the main 3 health concerns? *

What do you hope to achieve? *

How long are you committed to work on your health? *

Any additional comments or concerns you would want Trisha to know?

Assessing Readiness to Change

Please rate on a scale of 1 to 5 (1 being not important at all and 5 being very important): How willing are you to:

Likert Scale *

	1	2	3	4	5
1. Significantly modify your diet?	1. Significantly modify your diet? 1	1. Significantly modify your diet? 2	1. Significantly modify your diet? 3	1. Significantly modify your diet? 4	1. Significantly modify your diet? 5
2. Take several nutrition supplements each day?	2. Take several nutrition supplements each day? 1	2. Take several nutrition supplements each day? 2	2. Take several nutrition supplements each day? 3	2. Take several nutrition supplements each day? 4	2. Take several nutrition supplements each day? 5
3. Keep a record of everything you eat and drink in a day?	3. Keep a record of everything you eat and drink in a day? 1	3. Keep a record of everything you eat and drink in a day? 2	3. Keep a record of everything you eat and drink in a day? 3	3. Keep a record of everything you eat and drink in a day? 4	3. Keep a record of everything you eat and drink in a day? 5
4. Modify your lifestyle? (work demands, sleep habits)	4. Modify your lifestyle? (work demands, sleep habits) 1	4. Modify your lifestyle? (work demands, sleep habits) 2	4. Modify your lifestyle? (work demands, sleep habits) 3	4. Modify your lifestyle? (work demands, sleep habits) 4	4. Modify your lifestyle? (work demands, sleep habits) 5
5. Practice a relaxation technique?	5. Practice a relaxation technique? 1	5. Practice a relaxation technique? 2	5. Practice a relaxation technique? 3	5. Practice a relaxation technique? 4	5. Practice a relaxation technique? 5
6. Engage in regular exercise?	6. Engage in regular exercise? 1	6. Engage in regular exercise? 2	6. Engage in regular exercise? 3	6. Engage in regular exercise? 4	6. Engage in regular exercise? 5
7. Have periodic lab tests to assess your progress?	7. Have periodic lab tests to assess your progress? 1	7. Have periodic lab tests to assess your progress? 2	7. Have periodic lab tests to assess your progress? 3	7. Have periodic lab tests to assess your progress? 4	7. Have periodic lab tests to assess your progress? 5

STEP 2

After you submit this form (step 1) you will be emailed the Complete Medical Symptom Questionnaire fillable PDF. Fill this second form out and email it back to me. I will need this second form completed before our consultation.

Important to note:

Smart Wellness® is a virtual practice (can meet locally if interested). Appointments and correspondence are over the phone/video and electronic medical record keeps all of your records HIPAA safe.

Smart Wellness® does not accept insurance.

Trisha Howell MSH, RD, LD/N, IFMCP is not a Medical Doctor. She has her Master’s in Clinical Nutrition, a Registered Dietitian, Licensed Nutritionist in the state of Florida, and is highly specialized in Functional Medicine through a board-certified physician’s program with the Institute of Functional Medicine (IFM). She is the only IFM certified practitioner and Registered Dietitian in Jacksonville, Florida. Visit: IFM.org to see her profile information.

She is not able to order or discuss medications ever. You must seek medical advice from your family physician.

Comment

Remember to hit the submit button after you complete step 1.

VIRTUAL PRACTICE

Mailing Address:
4446-1A Hendricks Avenue
Suite 219
Jacksonville, FL 32207

Contact us

O: 904-803-5213
E: info@smart-wellness.com

Office Hours

By appointment only