Functional Medicine Intake
Complete it online at your own pace. An appointment is not required to begin.
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Your answers save as you go. Return later on the same device to finish.
Start Here →Talk It Through First
To speak with us before completing the form, schedule a phone consultation or call 704-663-2010.
Schedule a ConsultationAlready a patient here for chiropractic or acupuncture? Use this same link to begin functional medicine.
The intake is built around one goal: seeing your case as one connected picture instead of a list of separate symptoms. You complete it online, on your own schedule. An appointment is not required to begin.
Starting before you have an appointment
The intake asks for information most people have never assembled in one place. Diagnoses with the dates they occurred, every medication and supplement with its dose, surgeries, past environmental exposures, family history, and the order in which each of these happened. Different offices hold different portions of it, across as many years as you have been seeing providers, and some of it exists only in your own memory.
Completing the intake brings all of it into a single document. You keep that document whether or not you become a patient here. Print it, save it, or give it to any provider you see.
If you decide partway through the form that you want to speak with us, schedule from inside the form and return to the same section afterward.
Some people prefer to talk before writing anything down. During a phone consultation we discuss whether functional medicine fits your situation, and you complete the intake afterward if it does. Schedule one at the link above or call 704-663-2010.
Existing chiropractic and acupuncture patients who want to begin functional medicine use this same link. There is no separate form to request.
How your answers come together
As you work through the sections, your gut and digestive history, hormones, sleep, stress, toxic exposure, and the rest, the intake is built around a single question: how do these systems relate to each other in your case. Dr. Dudley reviews your answers as one connected set before your first visit, looking at where different systems point toward the same underlying issue, rather than reading each section on its own. That review is what shapes the first consultation, so the visit starts with the full picture instead of building one from scratch.
Medications and supplements
You document every prescription and every supplement, not only the ones a doctor prescribed, using whichever method is easiest: photograph the label and it gets read and added automatically, check off categories with dose and timing fields, or enter specialty products by hand. There's room to note when you started something and what you noticed afterward, because a supplement often begins as a response to a medication side effect that never gets mentioned to a provider. The intake also asks how your body tends to react to new medications and supplements in general, along with any known allergies, so a new plan gets paced to fit you rather than assuming everyone starts the same way.
Built to avoid repeating yourself
A diagnosis, an injury, or when a medication started, noted once, carries forward automatically into a timeline later, so you're not entering the same date twice. If you've already had certain testing done, including genetic testing, there's a place to record it, so care doesn't repeat work or recommend something that won't fit your biology.
Where it goes deeper than most forms
Environmental exposure questions reach back years, since exposure to heavy metals or chemicals decades ago still contributes to symptoms for some people today. Food reactions get split into the three types that respond to different treatment, immediate allergy, delayed sensitivity, and fermentation intolerance, rather than one general food question. And if memory or movement symptoms are part of what brought you in, a deeper module opens specifically for that, built on the same framework used in cognitive decline protocols.
Room for your story, not only your symptoms
This isn't only about data. Several sections, especially the health timeline, let you write in your own words instead of checking boxes. A checklist doesn't show what it's been like: normal labs when you know something's wrong, a symptom nobody has explained yet, or telling the same story over and over to people who never had time to hear all of it.
Write it however you'd normally explain it to someone. One person reads all of it, not as separate checkboxes, but as your story.
What happens with what you share
Your intake goes straight to Dr. John Dudley. No one else reviews it, and it doesn't sit in some general database. If you'd rather talk something through in person instead of typing it, tell us and we'll cover it at your visit.
4-day food log
Once you submit the intake, we automatically send a second, shorter tool to the same email: a 4-day food log (or you can fill it out directly from our website). It tracks your meals, macros, and calories, as well as your energy, digestion, mood, and sleep. This reveals how specific foods may affect you, not only what you eat in general. More on how it works on our food log page.
Common questions
Do I need an appointment before I fill this out?
No. Begin whenever you want. If you never become a patient here, you still finish with your health history recorded in one place, and it is yours to keep or give to another provider.
I already come here for chiropractic. Is there a different form?
It is the same form. Complete it and your functional medicine care starts from a full history instead of whatever fits into an adjustment visit.
What if I want an appointment partway through?
Schedule from inside the form. Your answers remain saved, and you return to the same section afterward.
How does the intake help identify connections between my symptoms?
Dr. Dudley reviews your full answers as one connected set before your visit, looking at where different systems, gut, hormones, sleep, stress, and the rest, point toward the same underlying issue rather than reading each section separately.
Do I have to list every supplement, even ones I only take occasionally?
Yes, where possible. Supplements interact with medications and with each other, and a partial list makes that harder to catch. Photograph labels, check off categories, or type them in by hand, whichever is fastest for you.
How long does the intake take to complete?
It depends on your history, since the form only shows sections relevant to you. Most patients spend it in a few sittings rather than all at once, and progress saves automatically along the way. Generally, 45-60 min.
Do I need to finish it in one sitting?
No. Your answers save as you go, so you leave and pick back up later on the same device.
What if I don't want to type out something sensitive?
Tell us, and we'll talk through it together at your visit instead. The form is there to help you prepare, not to replace the conversation.
Questions, or want to talk first? Call 704-663-2010.
This page describes our intake process. It is general information, not medical advice.