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Lauren J Colletti, FNP
Functional Medicine Practitioner
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ABOUT
HOW IT WORKS
PRICING
PROGRAMS
FOUNDATION TO WELLNESS
LOG-IN
Foundation to Wellness Survey
Store Program Login
FAQ
SERVICES
STORE
CONTACT
New Patients
Patient Portal
Landing Page-2 Variations
by Lauren Colletti
New Patient Application
Name
*
First
Last
Email
Best Phone Number
*
Date of Birth
*
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Age
*
Please enter a number from
16
to
99
.
Identifying Gender
Female
Male
Other
Identifying Gender Other
*
Appointments are primarily virtual, currently via Zoom. Do you have a reliable device and are comfortable with this format?
*
No
Yes
What are your Needs and Wants? What are you looking to resolve?
*
Please be as comprehensive as possible
What are your current symptoms and concerns?
*
Please be as comprehensive as possible
Have you been evaluated and or treated by another medical provider for this/these medical complaint(s)?
*
No
Yes
How many?
Do you suffer from severe anxiety, depression, rage,Bi-Polar, PTSD, OCD or any other Mental Health Issues?
*
No
Yes
Please lis details of anxiety, depression, rage,Bi-Polar, PTSD, OCD or any other Mental Health Issues.
Have you had any major diagnoses?
*
No
Yes
Please lis details of any major diagnoses.
How did you hear about Lauren Colletti FNP?
*
On a scale 1-10 How ready are you to:
(10 being I will do anything, 1 being I'm not that motivated)
Significantly modify your diet
10
9
8
7
6
5
4
3
2
1
Take nutritional supplements
10
9
8
7
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5
4
3
2
1
Keep an updated health journal
10
9
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5
4
3
2
1
Engage in relaxation techniques
10
9
8
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5
4
3
2
1
Modify your lifestyle
10
9
8
7
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5
4
3
2
1
Do regular Laboratory work to evaluate your progress
10
9
8
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6
5
4
3
2
1
Which statement resonates more with you
It’s the doctor's job to heal me.
It’s my job to heal myself with the guidance provided by Lauren Colletti FNP.
Our Patient Portal Application
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