Questionnaire

This isn’t your average doctor’s office - and that’s probably why you’re here! At Restore Balance, we take a whole-person approach to health, blending Western and Eastern medicine to help you restore physical, emotional, and spiritual balance. We believe that investing in your health is one of the best decisions you can make, but true healing takes time, commitment, and the right partnership.

That’s why our new patient process begins with a free consultation with one of our physicians. During this conversation, we’ll discuss your health concerns, goals, and expectations to determine if our approach aligns with your needs. If we’re a good fit, we’ll connect you with the right practitioner at RBIM to support your healing journey.

To ensure the best experience, we ask that you complete the form below with as much detail as possible. This helps us understand your unique health story and prepare for your consultation. Please check our FAQ page for additional information.

Ready to take the next step? Fill out the form below to request your initial appointment, and let’s start your path to better health together!

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First and Last Name:

Phone:

Email:

1. Are you ready to commit to your health mentally and financially?
* The minimum commitment to begin working with us is 3 months, but most patients benefit from 6-12 months.

YesNo

2. Do you have the financial resources to invest in your health?
* In order to be able to spend the time needed with you and to serve you best, we are out of network with insurances (read our FAQ for further details).

YesNo

3. What are the main issues (two to three) you would like addressed?

4. How long have these issues been present?

5. Who (or what) in your life has been negatively impacted because of your present level of health?

6. Why are you seeking a functional medicine approach?

7. Have you seen other integrative or functional medicine practitioners? How long?

8. Will you be able to have a series of office visits for evaluation and follow up?

9. In addition to having conventional lab tests, how motivated are you to invest in appropriate functional medicine lab testing that may not be covered by insurance to better understand exactly what's going on in your body? (from 1-5, 5 being very motivated)

* Orders for conventional labs (Quest, LabCorp, etc.) can be drawn locally. Most of our patients utilize their insurance plan for conventional labs, but this should be done at your discretion depending on your plan benefits.

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10. Will you be able to make changes in diet and lifestyle and take supplements if needed?

11. Are you comfortable with virtual telemedicine visits, online scheduling, and using secure portal messaging between appointments to communicate with our team?

YesNo

12. Where are you located?

13. How did you hear about us?

Thank you for taking the time to answer the above questions to the best of your ability.
We will get back to you after we review your answers and decide whether our practice is
a good fit for your healthcare needs.