Patient Intake — Dr. Brad Morris | Virtual Functional Medicine

Step 1 of 6

About You

Basic information to set up your patient record.

First Name *

Please enter your first name.

Last Name *

Please enter your last name.

Email Address *

Please enter a valid email address.

Phone Number

Date of Birth

State of Residence *

Please select your state.

Step 2 of 6

Your Health Goals

Select all that apply and tell us a bit more about what you're hoping to address.

Primary Concerns *

Weight Management Fatigue & Energy Hormonal Imbalance Digestive Issues Autoimmune Conditions Other

Please select at least one health concern.

Tell Us More

The more context you provide, the better we can prepare for your consultation.

Step 3 of 6

Medical Background

Help us understand your current medications and health history.

Current Medications & Supplements

Include prescription medications, over-the-counter drugs, and supplements.

Medical History *

Diabetes Thyroid Disorder Heart Disease Autoimmune Disease Mental Health Condition None of the above

Please select an option.

Step 4 of 6

GLP-1 Medication Interest

Answer these questions so we can determine if GLP-1 medications may be appropriate for you.

Current Weight (lbs)

Goal Weight (lbs)

Previous Weight Loss Attempts

Include diets, programs, medications, or procedures — what worked, what didn't.

Are you interested in exploring GLP-1 medications (e.g., semaglutide, tirzepatide)? *

Yes No Not sure yet

Please select an option.

Step 5 of 6

Lifestyle Basics

A few quick questions about your day-to-day. This helps us understand your current baseline.

Sleep Quality

Exercise Frequency

Stress Level

Step 6 of 6

Referral & Consent

Almost done — just a couple of quick questions before you submit.

How did you hear about us?

Consent *

I understand this is a preliminary questionnaire and not a medical consultation. Submitting this form does not create a doctor-patient relationship. Dr. Morris or a member of his team will contact me within 24 hours to discuss next steps.

Your Health History

Health history received