Patient Screening Form

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

Fill out the form below for a free Zoom consultation.

PLEASE COMPLETE THIS FORM

This form must be completed before the Zoom consultation can be scheduled.

Potential patient’s name: *

Email *

Phone *

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? *

Do you experience fatigue, brain fog, inability to lose weight and food sensitivities? If so, would you be interested in our 10 or 28-day metabolic detox? *

Is there anything else you would like to share that is important regarding your health?

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

What happens next?

After you submit this form you will be contacted from one of our team members to set up a free 30 min consultation.

Phone

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.

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