Functional Medicine Lab Test Intake

Functional Medicine Lab Test Intake — Form Fields

This healthcare template includes 12 fields. Intake form for functional medicine practitioners ordering comprehensive lab panels. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• Email (email, required)
• Phone Number (text, required)
• Primary Health Concern (dropdown selection, required) — options: Fatigue, Gut Health, Hormone Imbalance, Autoimmune, Thyroid, Metabolic, Brain Fog, Weight Resistance
• Lab Panels Requested (checkboxes, required) — options: Comprehensive Metabolic Panel, Complete Blood Count, Thyroid Full Panel, Hormone Panel, Food Sensitivity (IgG), Stool Analysis, Organic Acids Test, Micronutrient Panel, Cortisol (4-point), Inflammatory Markers
• Fasting Status (12 hours) (multiple choice, required) — options: Yes, No, Can Fast Tomorrow
• Current Supplements (text, optional)
• Current Medications (text, optional)
• Previous Functional Medicine Testing (dropdown selection, optional) — options: None, Within Past Year, 1-2 Years Ago, Over 2 Years Ago
• Pregnant or Nursing (multiple choice, optional) — options: Yes, No, N/A
• Symptoms and Timeline (long text, required)