Application | Dr. Justin Fortier

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Dr. Justin Fortier

Prospective Client Application

Please complete and submit. I use this to screen potential new clients. Nothing you enter will be the “wrong answer”, I am checking that what you’re dealing with will fit with my treatment program.

First Name

Last Name

Email

Birthday

Gender

Male

Female

Are you currently a patient of mine

Yes

No

Describe to me in as many words as you’d like your current condition that your seeking help with.

How long have you experienced this?

Was There a Date When This Condition Began?

Was There an Event That Created the Condition?

Have You Had This or Similar Condition in The Past?

What Makes It Better?

What Makes it Worse?

Any Food Make It Worse (Please List)?

Any Supplement Make It Worse (Please List)?

Worse Before After Or While Eating?

Is This Condition Interfering with Work Sleep Activity Other?

Please List Your Treatment Goals (Immediate and Future)

Are you willing to make dietary adjustments as needed to resolve it? Do you have dietary restrictions? Are you Vegan or Vegetarian?

Here’s a list of symptoms, check any if you’re experiencing:

Gassy

Excessive Gas

Gassy after eating

Loud gurgling after eating

Flatulence

Belching

Foul-smelling gas

Bloating or Distension

Abdominal Pain

Pain while eating

Pain after eating

Cramping

Heartburn

Feeling full after a few bites

Nausea

Headaches

Migraines

Joint/muscle pain

Itchy skin

Hives

Histamine Intolerance

Allergies

Sinusitis

Ringing in the ears

Fluid in the ears

Itching in the ears

Dry Cough

Dizziness

Difficulty Breathing

Asthma

Anemia

Insomnia

Sleeping problems

Can’t fall asleep

Can’t stay asleep

Gingivitis

Tooth decay

Low ferritin

Low B12

Low iron

Are you having difficulty achieving daily tasks

Do you experience nervousness

Anxiety

Mild depression

Hair loss

Low blood sugar

Heart palpitations

Loss of stamina or muscle strength

Legs getting tired

Restless Leg

Acne

Non-Alcoholic Fatty Liver

IBS

Diarrhea

Constipation

Crohn’s or Ulcerative Colitis

Celiac

Chronic Fatigue Syndrome

Fibromyalgia

Gallbladder Problems

Osteoporosis

Do you have Fatigue

Feeling a lack of energy not relieved by sleep or a good rest

Are you energized in the evenings

Difficulty losing weight

Slow to recover from illness like a cold or the flu

Do you get illnesses often like cold or flu

Brain Fog

Obsessive Compulsive disorder or tendencies

Attention deficit

Hyperactive

Impaired memory or problem solving

Difficulty concentrating

Unexplained fears or paranoia

Choppy thought process

Tourette’s or Tic’s

Loss of feeling of overall well-being

Weight loss

Malabsorption

Do you have lines or grooves on your fingernails

Do you have any yellow or damaged looking nails

Do you have rosacea

Hypothyroid

Lactose Intolerance

Hypoglycemia

Chronic Pain

Chronic Pancreatitis

Cystitis

Do you crave salty foods or sugary foods

Do you get lightheaded

Do you need caffeine or energy drinks to get going in the morning

Do you shake or tremble when stressed

Do you forget things easily

Do you feel difficulty handling stress

Do you feel overwhelmed

Are you always thirsty or find yourself carrying a water bottle around

Do you have low body temperature

Do you have a low sex drive

If Gassy after eating, how long after?

Do you have food sensitivities? What symptoms do they cause you to have?

Do you have an autoimmune disorder (s)?

If you have Anemia? How long have you had it?

Diarrhea, Constipation, or both? Have you any thoughts on what might have caused it?

Do you get Cramping? Where? When? Notice any triggers?

Pain while eating or Pain after eating How long after? Have you noticed any foods that cause it to hurt? Any specific time of day?

Thank you very much for your time filling this out! I will be back with you promptly, usually within 24 to 48 hours to let you know if you’re a candidate for my program.

Thanks -Dr. J

Phone/Address

972-839-9926

4961 Long Prairie Rd suite 130

Flower Mound, TX 75028

Email

Fortierchiro@gmail.com

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© 2022 By Justin Fortier.
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