PDF Forms to Download (For PC, tablets and laptops)

Is one of the essential tools in Functional Medicine to help us understand your health condition, explain why the condition occurs and to find the root cause of the disease. Basically, you will provide details of your life from preconception/birth up to the present time as shown below. You will include birth history, diagnosis, symptoms, events (e.g.marriage, job, pregnancy, trauma, crisis), environmental exposure/toxins, diet & lifestyle in chronological fashion with details of age or year.

Antecedents are factors, genetic or acquired, that predispose an individual to a disease, diagnosis, or dysfunction. List down the illnesses/diseases that runs in your family (i.e. parents, siblings, uncle/aunt, grandparents). Include the age that they got the diagnosis or age of death as a result of the disease (if applicable). As mentioned, it can also be acquired. For example: poor nutrition, insufficient sleep, sedentarism, stress, isolation and loneliness.

Triggers are episodic exposures, factors, or life events that immediately provoke(d) the symptoms and signs of the conditions. List down the possible triggers of your current illness. For example: dust, smoke, pollens or after a stressful divorce or pregnancy

Mediators are current and ongoing biochemical, environmental, lifestyle, or psychosocial factors that contribute to physiological dysfunction, perpetuate the medical condition, and prevent the restoration of health. In other words, factors that are excessive or deficient in your life. For example: excess body weight, stress, processed foods or lack of sleep, exercise, nutritious food, vitamins/minerals, sunlight or access to healthcare.