JFTHOI Functional Medicine Intake Part 4



Do you engage in yard work that involves working in soil?(Required)
Are you located within a few miles of streams?(Required)
Do you have cats in your yard (either pets or strays)?(Required)
Have you experienced bug bites, such as from ticks, brown recluse spiders, or unidentified sources?(Required)

Home Safety

Do you have a basement in your home?(Required)
Have any of your windows leaked or are in poor condition?(Required)
Do you have gas appliances or a fireplace?(Required)
Is your HVAC system located in a crawlspace?(Required)
Have you experienced roof leaks?(Required)
Is there visible mold in your shower, or do you detect a moldy smell, or have a history of mold issues without visible signs or smell?(Required)
Have you used strong chemicals to treat any issues in your home, or is there a history of insurance claims from previous owners?(Required)


Do you floss regularly?(Required)
Have you had any dental surgeries?(Required)
Do you use an oral rinse or wash?(Required)
Do you use a nasal rinse, spray, or wash?(Required)
Do you use mouth probiotics?(Required)
Do you take dietary probiotics?(Required)
Do you have a history of nosebleeds?(Required)
Do you have receding gums?(Required)

Other Health Concerns

Have you had eye surgeries, such as LASIK?(Required)
Do you experience balance issues?(Required)
Do you suffer from rashes?(Required)
Do you sweat excessively?(Required)
Have you experienced hair loss?(Required)