Welcome to Functional Medicine SF Thank you for your interest in working with Functional Medicine SF. The office of Stephanie Daniel D.O., & Lisa Deptula P.A., Please visit our website, functionalmedicinesf.com, for additional information Please do not hesitate to email us with any questions or comments you may have at [email protected]. At this time, Dr. Daniel accept patients, aged 18 and over If you are under 18, please contact our staff at [email protected] Thank you! Please check the boxes below to indicate that you meet these basic requirements. What Provider are you Interested in?*Stephanie Daniel D.OAre you 18 years of age or older?*Yes, I am 18 years of age or older.No, I am not at least 18 years of age.What are your Functional Nutritional Needs and Wants?*Please be as comprehensive as possibleHow many doctors have you been to for this medical concern?0-23-67-10Provide information on all the specialist you have been to:Allergist, Cardiologist, Dermatologist, Endocrinologist, Epidemiologist, Gynecologist, Immunologist, Infectious Disease Specialist, Microbiologist, Neurologist, Oncologist, ENT Specialist, Psychiatrist, Rheumatologist, UrologistSpecialtyNameDate Do you consider your health stable, with no hospitalizations in the past year?*YesNoPlease explain details:*Do you have severe neurological conditions such as seizures, loss of consciousness, fainting or autonomic instability?*YesNoPlease explain details:*Do you have MS (multiple sclerosis), ALS (amyotrophic lateral sclerosis) or Parkinsons? **YesNoPlease explain history of illness*Do you suffer from severe anxiety, depression, rage,Bi-Polar, PTSD, OCD or any other Mental Health Issues?*YesNoPlease explain details*How did you hear about FMSF*Are you male of female*MaleFemaleAge*Please enter a value between 0 and 99.Have you been evaluated and or treated by another medical provider for this medical complaint?*Yes, I have been to other providers for this medical complaint.No, I have not been to other providers for this medical complaint.Current Medical Diagnosis and Complaints*Medical Diagnosis and ComplaintsDate Symptoms Started Are you currently taking any medications?*No, I do not take medicationYes, I take medicationListName Of MedicationDosageDate Started 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*10987654321Take nutritional supplements*10987654321Keep an updated health journal*10987654321Engage in relaxation techniques*10987654321Modify your lifestyle*10987654321Do regular Laboratory work to evaluate your progress*10987654321Which 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 FMSFFunctional Medicine SF Policy Acknowledgement Click here to read the PoliciesHave you read and understood the policies of FMSF*No, I have not read and or do not understand the policies of FMSFYes, I have read and understand the policies of FMSFFunctional Medicine SF, How it works Click here to read How it worksHave you read and understood how FMSF works with patients*No, I have not read and or do not understand how FMSF works with patientsYes, I have read and understand how FMSF works with patientsI understand Functional Medicine SF does will not bill or submit to any insurance agency or Medi-care or Medi-Cal*We provide SupperBills for you to provide to your respected medical insurance carrier or system.Yes, I understand I must provide payment at time of service.No, I want to submit the bill to my insurance carrierNo, I want to use Medicare or Med-iCalYou understand we FMSF is complete Virtual Medical Practice.*All medical appointments take place via Video Conferencing. Yes ,I understand FMSF is a complete Virtual Medical Practice.No, I do not understandYou understand you must attend the Wednesday at 5 PDT Zoom Webinar : https://zoom.us/j/231386330*Please Join me every Wednesday at 5, for a question and answer Zoom webinar: Yes, Ill be there.No, I cant make it.Name* First Last Email* Phone****IMPORTANT NOTE: This will take you to a short video that completes the application. Please add the domain “@functionalmedicinesf.com" to your contacts/safe senders list in your email client or the confirmation email will be sent to your spam folder*** This iframe contains the logic required to handle Ajax powered Gravity Forms.