Patient Application Form Order Number First Name * Last Name * Date of Birth * Address * City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana IAIowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Phone * Email * What are your top 3 challenges that you would like us to help you overcome? Why are these health goals important to you? * What is stopping you from accomplishing these goals? * If you were to wake up tomorrow without these challenges, how would your life be different? * What are the top factors that motivate you to invest in these problems? * Do you have a strong support system to help you in this journey? (e.g., family, friends, significant other) * On a scale of 1-10, how coachable do you feel you are? * 5 1 being NOT very coachable and 10 being very coachable. What are the characteristics you value in a doctor-patient partnership? * How do you best learn? (e.g., reading materials, videos, podcasts) * Who else have you worked with? * Functional Medicine Practitioner Integrative Medicine Physician Medical or Osteopathic Doctor Naturopathic Doctor Traditional Chinese Medicine Practitioner Nutritionist Personal Trainer Chiropractor Personal Development Coach Other: What functional lab testing have you had done? * Functional Stool Testing Organic Acids Testing Genetic or Genomic Testing Hormone Testing Heavy Metal Testing None Other Considering your past treatments, what would you like to improve or do differently moving forward? * Are you willing to do what is necessary to improve your health (dietary changes, lab testing and/or lifestyle modifications)? * Are you willing to invest in a personalized health plan that would address your health and wellness goals and have long lasting effects? * Yes No Would you be interested in joining a Facebook group hosted by our practice? The purpose of the group is to share health and wellness information and provide you with an opportunity to ask general questions about healthy lifestyle and nutrition. * Yes No How did you hear about us? * IFM website Google search I was referred by my doctor or practitioner Podcast Event Facebook Instagram Referred by a friend Other What are your top three health and wellness questions you would like us to address in our future content? * Email Consent Add me to Dr. Bojana's health letter. I want to receive the latest health news, practical wellness tips and recipes from Dr. Bojana. I understand that my email will not be shared with anyone, and that I can opt out anytime.