New Client Screening New Client Screening Thank you for interest in the services that The Hoffman Centre for Integrative Medicine can offer you in the pursuit of your health. In order for our staff to best assist you, please complete the following questionnaire. We are honored to be part of your healing journey. Our goal is to empower you to make conscious decisions about your health and wellness. As a functional medicine practice, we work with you to identify and address the root cause or causes of your health symptoms so that you can reach your wellness goals. Our team has extensive training in functional medicine, nutrition, and with regards to Dr. Hoffman’s Seven Stages to Health and Transformation Model ™. We believe this integral approach allows for true healing. We pride ourselves in addressing the entire person, rather than simply the disease, and in creating authentic partnerships between the client and consultant. Our practice is unique in the functional medicine field due to our personalized and expanded diagnostic and treatment approaches. These are far more expansive than the services offered by a standard functional or integrative medicine clinic. Most of Dr. Hoffman’s patients have been referred by, or have already consulted with, many other functional medicine or traditional medicine practitioners without achieving the desired results. Following an intake process that takes between two and three hours, we offer a large array of diagnostic test options, test recommendations, test interpretations, and personalized wellness programs. Educating patients on the underlying biochemical pathways that contribute to their health issues is paramount in our approach. Whether you’re newly diagnosed with a health condition or have been on your health journey for many years and are stalled in your efforts to reach true wellness, we invite you to learn more about our services. We look forward to helping you achieve vitality and optimal health. This short survey provides us with a snapshot of your needs and desires related to your anticipated outcome. Upon completion of the survey, one of our patient care assistants will contact you to discuss our services and help you determine how we might best attend to your needs. Please note the questions marked with an asterisk are mandatory. Personal informationName First Last Gender*MaleFemalePrefer Not to AnswerDate of Birth* Date Format: MM slash DD slash YYYY Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Address Home PhoneMobile PhoneAre you completing this survey for yourself or on behalf of another person?*MyselfAnother PersonIf for another person, what is their relationship to you?We'd love to know how you found us or who referred you. Please first choose a category and then provide us the specific information.*Personal referralDoctor/practitioner referralGoogle SearchSocial mediaVideo or summitLive eventWebsiteOtherPersonal Referral - Who?Doctor/practitioner Referral - Who?Google Search - What word or words did you use?Social Media - Which platform?Live Event - Which One?Video or Summit - Which one?Website - Which one?Other- Please Specify?What are your main goals in seeking functional medicine consulting services at The Hoffman Centre?*Please be very specific so that we can best align your needs with the most appropriate patient care assistant.*What are your top five symptoms?* Do you have any known health or medical conditions or diagnosis that we should be aware of when helping you to find the best care? If so, please complete the information in the following section. **YesNoMedical diagnosis*DiagnosisCurrentPastDate of Onset Medical Diagnosis NotesAre you currently taking any pharmaceutical prescription medication?*YesNoIf so, please indicate the medication, dose, and reason for the prescription below. For example, Lisinopril, 20 mg/day, high blood pressure.MedicationDoseReason for Prescription Have you been hospitalized in the last year? If so, what was the reason and for how long did you remain in hospital?HospitalizationDateReason Have you consulted with medical specialists, naturopathic doctors, or worked with any other healthcare providers? This includes chiropractors, dentists, acupuncturists, psychologists, or dieticians. If so, please list these below and be very specific regarding names and dates.Specialist TypeSpecialist NameApproximate Date Have you had surgery in the last two years? If so, please explain.SurgeryDateReason Have you had surgery in the last two years? If so, please explain.SurgeryDateReason What have you tried so far, such as diets, testing, or modalities, to meet your goals? Please check all that apply.(Hold down Ctrl/CMD + Click)*Not much, I’m just getting startedI’ve tried a few things, but I’m overwhelmed by all the information that’s availableI’ve visited more than three practitioners trying to figure this out, but understanding or relief is still a mysteryI’ve worked with another functional medicine practitioner and am interested in further exploring my health concernsOtherOther - Please SpecifyWhat is the most frustrating aspect of your symptoms or health condition?*What is your level of readiness and commitment on a scale of 1 to 10, with one being the lowest and ten being the highest, to significantly modify your diet and lifestyle, take supplements as recommended, engage in functional medicine laboratory testing, and explore your lifestyle practices and possibly psychological issues in order to make any potential life-transforming changes?* Which of the following items are currently part of your diet, in any amount? Please select all that apply.(Hold down Ctrl/CMD + Click)*SodaDiet sodaRefined sugarAlcoholFast foodSnack foods (chips, pretzels)Dessert/candy (chocolate, cookies, candies, Twinkies)Gluten (wheat, rye, barley, spelt, kamut)Dairy from any animal source (milk, cheese, yogurt)Coffee/caffeineOtherOther - Please SpecifyHow prepared are you to make radical revisions to your dietary approach, in order to achieve optimal nutritional levels while lowering any potential inflammatory triggers?*List any food or environmental allergies that you experience.Food/Environmental allergiesReaction What percentage of your meals are currently prepared at home? **Less than 25%25-50%50-70%70-100%Over the last few years, how much do you estimate you've financially invested in trying to solve your health issues? Consider such aspects as copays, medications, supplements, programs, and your time.*Please note that this individualized functional and integrative medicine approach has resulted in incredible health transformations for clients in as little as four to six months. Sometimes it may take much longer depending on the age of the patient, the length of time they’ve been ill, the number of organs or biochemical pathways that are affected, and genetic predispositions. Other determining factors include concurrent mental health challenges, defenses and types of resistance faced by the patient regarding self-empowerment, and self-advocacy in doing what it takes to get well, and the support services that are available. One of the major challenges facing patients with complex illnesses that feel as though they’ve been everywhere and seen everyone and who now want a functional or integrative medical approach, is that this approach falls under the mantle of private medicine. In fact, it’s illegal to charge the Canadian healthcare system for what they term an alternative or complementary medicine approach. Dr. Hoffman refuses to manage patients based solely on symptoms and the name of a disease. Furthermore, most patients with complex presentations from other practitioners have very often had woefully inadequate workups and have fallen far short of the number of laboratory tests that are required in order to develop a comprehensive diagnostic and therapeutic program. Consequently, in order to achieve maximum insight into disease or symptom processes, Dr. Hoffman conducts extensive laboratory testing with American and European laboratories, which aren’t covered under any healthcare plans. In addition, in his diagnostic workup Dr. Hoffman investigates inherited family system trauma, early developmental trauma, stress responses, psychological profiles and defense mechanisms, in addition to brain and mind/body determinants. This diagnostic approach requires an average emotional and financial investment of between $10,000 and $15,000 in laboratory test costs alone. These costs may be significantly higher if there are many symptoms, multiple diagnoses, and multiple visits to numerous practitioners. Dr. Hoffman will closely study every consultation conducted by previous practitioners, as well as testing carried out within the previous three months and whatever treatments plans have been initiated to date. We require that you assist our staff in compiling a comprehensive past medical dossier. We regret that current medical approaches to illness do not, at this stage of medical knowledge and funding, financially support these programs. Are you able and/or prepared to take action and emotionally and financially invest in yourself to achieve your health goals?*YesNoCommentsWe’re committed to working with individuals who are dedicated to their health and ready to receive support on their individualized journey to wellness and healing. We’re uniquely poised to uncover and unlock the evolving protocols that will deliver the results you've been seeking. In two or three sentences, tell us something about yourself or concerning your health history that will help us get to know you before we take any further steps to further explore the details of your concerns.**Thank you for taking the time to provide us with this important information. Once completed, please click SUBMIT and we will contact you within 24 to 48 hours.