Patient Screening Form

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

Fill out the form below for a Zoom consultation.

PLEASE COMPLETE THIS FORM FIRST, THEN SCHEDULE YOUR 30-MINUTE CONSULT

This form must be completed in order to meet with Trisha. After submitting your responses, you will be taken to Practice Better to schedule your first 30-minute Zoom consultation.
Assessing Commitment
Assessing Readiness to Change

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

Not willing at all (1)Somewhat less willing (2)Willing (3)Somewhat more willing (4)Very willing (5)
1. Significantly modify your diet?
2. Take several nutrition supplements each day?
3. Keep a record of everything you eat and drink in a day?
4. Modify your lifestyle? (work demands, sleep habits)
5. Practice a relaxation technique?
6. Engage in regular exercise?
7. Have periodic lab tests to assess your progress?

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 but can provide a superbill that you can give to your insurance company-No guarantees as not all insurance companies recognize functional medicine visits.

 

 

 

 

 

VIRTUAL PRACTICE

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

Contact us

By filling out an inquiry and booking a consultation.

Office Hours

By appointment only