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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
6
5
4
3
2
1
Keep an updated health journal
10
9
8
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5
4
3
2
1
Engage in relaxation techniques
10
9
8
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6
5
4
3
2
1
Modify your lifestyle
10
9
8
7
6
5
4
3
2
1
Do regular Laboratory work to evaluate your progress
10
9
8
7
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.
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