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 AND date of birth (DOB): *

Email *

Phone *

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

Assessing Commitment

What are the main 3 health concerns? *

Please address the following questions: Why functional medicine, why now and why Trisha Howell? *

Do you experience fatigue, brain fog, inability to lose weight and food sensitivities? If so, would you be interested in our 10 or 21-day gentle metabolic detox? *

Would you be interested in learning about our group 12-week lifestyle medicine to lose weight, reduce risk for prediabetes and/or diabetes, cardiometabolic and other chronic diseases?

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

Phone

Next Step - Schedule Your FREE 30-minute consultation

After you submit this form, please click the link below to schedule your call with Trisha.

This button will take you to the calendar app on the Practice Better site.

Start your healing journey

Important to note:

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 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 board-certified functional medicine nutritionist in Jacksonville, FL and is 1 of 5 in the state of Florida.

She is 100% virtual. She is fee for service practice not insurance based.

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