Functional Health Management Score

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Your Complete Guide to Lifetime Patients and Clients

Making the Invisible Visible

Learn the only one way to make Lifetime Patients and Clients

Functional Health Management Score™

Find out your personal chances of getting well and staying well by taking a few short minutes to answer these simple questions. Once completed we will contact you to review your results.

Step 1 of 5

20%

Do you currently have a health problem or symptom that you would like addressed?*
- Yes
- No
Health Problem*
Please briefly describe your current health problem.
Health Goal*
If you have a specific goal you would like to achieve rather than deal with any specific health problem, please briefly describe it below.
What area(s) of your body are bothering you the most? (mark all that apply)**
- Back or Neck Pain
- Muscle Aches or Pains
- Knee, Hip or Ankle Pain
- Shoulder, Elbow or Wrist Pain
- Headaches
- Fatigue
- Digestive Issues
- Cardiovascular/Blood Pressure Issues
- Diabetes
- Hormone Imbalance
- Other
How long has the problem been going on?
Place an "X" next to ONLY ONE answer that best describes you.
- Just started today
- A few days
- A few weeks
- A few months
- A year or longer
Please describe the frequency of your symptom(s)*
Place an "X" next to ONLY ONE answer that best describes you.
- Rare
- Intermittent
- Occasional but daily
- Frequently everyday
- Constant
Please indicate the intensity of your symptom(s)
Place an "X" next to ONLY ONE answer that best describes you.
- Mild
- Annoying
- Medium
- Getting worse
- Intense
Does your symptom(s) interfere with your daily activities?*
Place an "X" next to ONLY ONE answer that best describes you.
- No
- Only occasionally
- Can’t do certain activities
- Frequently - all activities are restricted
- Extremely limited in all activities
Whom have you seen already in an attempt to correct your health challenge or reach your health goals?*
Please check all that apply.
- Primary Care physician
- Chiropractor
- Physical Therapist
- Nutritionist
- Naturopath
- Functional Medicine Specialist
- Medical Specialist (Orthopedist, Neurologist, Endocrinologist, etc.)
- I have self-treated
- I have done nothing at this point
Please indicate the outcome from any of the above.*
Place an "X" next to ONLY ONE answer that best describes you.
- No improvement
- Slight or temporary improvement
- 25% improvement
- 50% improvement
- 75% improvement

ELIMINATION*
If you are unable to urinate or defecate please indicate how long this is going on under "Other". This could be considered a medical emergency and should be dealt with as such.
- 2-3 BM's per day
- often need laxatives to have a BM
- 1 BM per day usually
- often have diarrhea
- tend to be constipated
DIGESTION*
Place an "X" next to ONLY ONE answer that best describes you.
- excellent, no complaints
- pain, leaky gut, Crohn's, reflux, ulcers, H.pylori
- occasional burping and/or intestinal gas
- tend to get burping, heartburn, bloating, gas, indigestion
- strong, frequent digestive complaints
WEIGHT*
Place an "X" next to ONLY ONE answer that best describes you.
- at ideal weight (weight that I look and feel best)
- significantly overweight
- 10 pounds overweight or underweight
- hard to maintain ideal weight
- very hard to lose weight

EXERCISE*
Place an "X" next to ONLY ONE answer that best describes you.
- exercise every day
- sedentary, rarely if ever exercise
- exercise 4-5 times a week
- exercise 3 times a week
- exercise 1-2 times a week
How much water do you drink each day?*
Place an "X" next to ONLY ONE answer that best describes you.
- half my body weight in ounces
- I don't drink any water
- a gallon of water
- a glass of water
- I get my water primarily from coffee and tea
DAILY DIET*
Place an "X" next to ONLY ONE answer that best describes you.
- little or no organic foods
- 80-100% whole, natural organic foods
- 60-80% whole, natural organic foods
- about 50% organic, 50% non-organic
- often hungry, have cravings, for processed foods or sweets

SLEEP*
Place an "X" next to ONLY ONE answer that best describes you.
- sleep well, 7-8 hours per night
- sleep problems, sleep deprived
- sleep OK, 6-7 hours usually
- fall asleep but wake up and can’t go back to sleep
- have trouble falling asleep
ENERGY*
Place an "X" next to ONLY ONE answer that best describes you.
- have great energy through the day and evening
- low energy, fatigue, need stimulants (coffee, tea, etc.)
- generally have pretty good energy, could have more
- good energy except afternoons, after lunch
- energy goes up and down, tends to be low
IMMUNITY*
Place an "X" next to ONLY ONE answer that best describes you.
- excellent immunity, rarely sick, get well quickly
- often sick, hard to get well, long recovery time
- occasionally sick but get well soon
- get sick when stressed or run down
- tend to catch anything that comes around
MIND - EMOTIONS*
Place an "X" next to ONLY ONE answer that best describes you.
- no mental or emotional complaints
- "brain fog" or anxious or depressed often
- mind OK but not what it was, some moodiness
- bad memory, forgetful, and/or up and down moods
- some focus issues, sometimes anxious or depressed

SMOKING*
If you currently smoke tobacco or have smoked tobacco in the past one to two years check Yes.
- Yes
- No
ALCOHOL*
If you currently drink any alcohol regardless how much or how little check Yes.
- Yes
- No
RECREATIONAL DRUGS*
If you currently use recreational drugs regardless of type or frequency check Yes.
- Yes
- No
MOTIVATION*
Rate your MOTIVATION to follow a health-building program on a scale from 1-10, with 1 being the lowest level of motivation and 10 being the highest level
Please enter a number from 1 to 10.
WILLINGNESS*
Rate your WILLINGNESS to follow a health-building program on a scale from 1-10, with 1 being the lowest level of willingness and 10 being the highest level
Please enter a number from 1 to 10.
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