Patient Forms

New Patients:

• If you are new to Healing Family Functional Medicine, or a returning patient from our previous practice, please complete our Individual (Adult & Child) New Patient Questionnaire
• If you have more than one child scheduling as new patients, please complete our Multi-Child New Patient Questionnaire
• For all current and former patients of the Cleveland Clinic, please also complete the Cleveland Clinic Dr. Connect Release Form. For fastest processing, you can find an electronic version of this form in Mychart under Your Menu > Sharing > DrConnect Authorization. This will allow Dr. Patel to access your medical records an previous test results electronically.  

Follow-Up Patients: 

• Please complete a brief Follow-up Patient Questionnaire prior to each follow-up appointment. 

Clinical Questionnaires (if requested by Dr. Patel only): 

• Horowitz Lyme-MSIDS Questionnaire
• Medical Symptom/Toxicity Questionnaire (MSQ)
• Mold Toxicity Questionnaire
• Promis Global Health Questionnaire
• Release of Medical Records (From another facility to Healing Family Functional Medicine