Your Chronic Conditions
Check any conditions you have been diagnosed with or are actively managing. Include past diagnoses that still affect you.
Autoimmune & Inflammatory
Metabolic, Endocrine & Hormonal
Cardiovascular
Digestive & Gut
Neurological, Cognitive & Mental Health
Chronic Fatigue, Pain & Complex Illness
Skin, Women’s & Men’s Health
Other Chronic Conditions
Additional details about your conditions
Current Medications & Care
Some supplements interact with prescription medications. Dr. Thomas uses this information to design a safe, complementary protocol.
All current prescription medications with dosages
Drug allergies and adverse reactions
Other providers you currently see
Relevant Lab Results
Recent labs help Dr. Thomas identify nutrient gaps and design a targeted protocol. If you have not been tested, select “Never tested” — appropriate labs will be ordered at your consultation.
Vitamin D level
Select…
Optimal (50-80 ng/mL)
Sufficient (30-50 ng/mL)
Insufficient (below 30)
Deficient (below 20)
Tested but do not know result
Never tested
Vitamin B12 level
Select…
Optimal (above 500 pg/mL)
Low-normal (200-500)
Deficient (below 200)
Tested but do not know result
Never tested
Ferritin / Iron
Select…
Optimal
Low (iron-deficient)
Elevated (possible overload)
Tested but do not know result
Never tested
Thyroid status
Select…
Normal
Hypothyroid — on medication
Hyperthyroid
Autoimmune (TPO or Tg antibodies)
Tested but do not know result
Never tested
HbA1c (blood sugar)
Select…
Optimal (below 5.4)
Normal (5.4-5.6)
Prediabetic (5.7-6.4)
Diabetic (6.5 or above)
Tested but do not know result
Never tested
Inflammation (hs-CRP)
Select…
Low (below 1.0)
Average (1.0-3.0)
High (above 3.0)
Tested but do not know result
Never tested
Homocysteine / methylation
Select…
Optimal (below 8)
Borderline (8-12)
Elevated (above 12)
Tested but do not know result
Never tested
MTHFR genetic variant
Select…
Normal
Heterozygous variant
Homozygous / compound variant
Tested but do not know result
Never tested
Specialty testing you have completed
Other lab results you’d like Dr. Thomas to know about
Nutrition & Digestion
How your body absorbs nutrients directly affects supplement effectiveness. Please share as much as you can.
Diet pattern
Select…
Standard American diet
Mediterranean or whole foods
Low carb or keto
Mostly plant-based
Autoimmune paleo (AIP)
Gluten-free / dairy-free
Elimination diet
No structure — varies daily
Meals per day
Select…
1
2 (may include intermittent fasting)
3
4 or more (grazing / small meals)
Foods you avoid or cannot tolerate
Digestive symptom severity
Select…
None — digestion is comfortable
Mild — occasional discomfort
Moderate — daily but manageable
Severe — major impact on life
Bowel movement frequency
Select…
Once daily
2-3 times daily
Every other day
Less than every other day
Irregular / unpredictable
Current Supplements
Please list what you are already taking so Dr. Thomas can adjust rather than duplicate, and identify any gaps.
All current supplements with dosages
Prior supplement history
Select…
Never taken supplements consistently
Some experience — basic multivitamin
Moderate experience — several targeted supplements
Extensive experience — functional medicine protocols
Preferred supplement form
Select…
Capsules or tablets
Powders
Liquids or tinctures
Gummies
Any form is fine
Have difficulty swallowing pills
Supplements you have had negative reactions to
Supplements that have worked well for you
Monthly supplement budget
Select…
Under $50
$50-100
$100-200
$200-400
$400+
Not a limiting factor
Willing to take how many supplements per day?
Select…
Minimal — 1 to 3 items
Moderate — 4 to 6 items
Willing — 7 to 10 items
No limit — whatever is clinically needed
Lifestyle Factors
Sleep quality
Select…
Excellent — restorative
Good — most nights
Fair — inconsistent
Poor — frequently unrefreshing
Very poor — disabling insomnia
Stress level
Select…
Low
Moderate
High
Very high — chronic stress
Exercise frequency
Select…
Sedentary — no regular exercise
Light — walking 1-2 times per week
Moderate — 3-4 times per week
Active — 5 or more times per week
Limited by symptoms or illness
Daily water intake
Select…
Less than 32 oz
32-64 oz
64-100 oz
More than 100 oz
Alcohol use
Select…
None
Occasional (1-3 drinks per week)
Moderate (4-7 drinks per week)
Heavy (more than 7 drinks per week)
Tobacco or nicotine
Select…
Never
Former user
Current smoker
Vaping or e-cigarette
Nicotine pouches or gum
Known environmental exposure
Select…
None known
Mold exposure (home or work)
Heavy metal exposure
Occupational chemical exposure
Multiple or suspected
Pregnancy status (if applicable)
Select…
Not applicable
Not pregnant / breastfeeding
Currently pregnant
Currently breastfeeding
Actively trying to conceive
Your Goals & Priorities
What are your main goals? (check all that apply)
What is your biggest hope for this consultation?
What have you already tried that has not worked?
Willingness to make lifestyle changes
Select…
Very willing — ready to change diet, sleep, and habits
Moderately willing — prefer supplements do most of the work
Limited willingness — want mostly a supplement plan
Depends on the specific change
Timeline expectations
Select…
Understand this takes months to see full results
Hoping for improvement within 4-8 weeks
Looking for shorter-term boost
Committed long-term to root-cause work
