Take this simple questionnaire and someone from our office will be in contact with you and review your questionnaire results Step 1 of 3 33% Name* First Email* Part 1: Where Are You Beginning?Have you been diagnosed with an autoimmune disease? (Graves, Hashimoto's, Type 1 Diabetes, Celiac, Crohn's, MS, Rheumatoid Arthritis, etc)YesNoAre you following any specific dietary protocol? (AI, Paleo, AI Paleo, SCD, GAPS, Low FODMAP,etc)YesNo Part Two: What Are Your Symptoms?Skin Acne Skin rashes Eczema Hives Rosacea Skin or Nail Fungal Infections (athlete's foot, ring worm, toenail fungus, etc.) Mind/Emotions-Mental Health Anxiety Depression Mood Swings Brain Fog Difficulty Concentrating ADD/ADHD Hormone Imbalances Male Hormone Imbalances Irregular Periods PCOS PMS Infertility Uterine Fibroids Endometriosis Menopause Digestive Tract Belching Bloating Constipation (less than 1-3 bowel movements a day) Diarrhea/Loose Stools Nausea or Vomiting Gas Foul smelling stool or gas Stomach Pain Intestinal Spasms Heart Burn and Acid Reflux IBS, Crohn's or Ulcerative Colitis Diagnosis Joint/Muscle Arthritis Joint Pain Joint Swelling Fibromyalgia Head/Nose/Lungs Asthma Congestion Dizziness Headaches Stuffy Nose Seasonal Allergies Energy/Sleep Fatigue/Chronic Fatigue Low Energy Insomnia Sleep Disturbance Other Low White Blood Count Autoimmune Disease Cancer Frequent Illness Thyroid Imbalance Weight Gain Vaginal Yeast Infections Itching (rectal, vaginal, ears) Carb or Sugar Cravings I Never Feel Full or Satisfied After I Eat Iron Deficiency B12 Deficiency I have Traveled Internationally I Have Had Traveler's Diarrhea I Have Had Food Poisoning and Never Felt the Same Since Histamine Intolerance Part 3: ConclusionI have a few other questions for you which will help me understand how to most effectively help you and determine the best place to start with you. If you were to list your 3 main concerns, what would they be in order of most importance? How would YOU describe the complexity of your condition?1. Mild complexity (little to No impact on quality life)2. Moderate complexity (affects most aspects of my life)3. Severe complexity (I have been to numerous doctors and I am still suffering without answers as to why I feel the way I do)What Do you feel you need the most help with?A) Just a bit of help- dietary changes and implementing those changes. Meal planning and recipes for SCD diet, Low FODMAP, Paleo, AI Paleo, etcB) I Need a Second Opinion- I’ve been to another Functional Medicine Doctor, have had some testing and I’m just not sure about everything. I feel something is just missing.C) Big Picture Approach- I need Dr Hagmeyer to thoroughly review my case. I need help with all aspects of treatment- Diet, Meal Planning, Recipes, Supplementation, Lifestyle, etcD) I'm in Bad shape- I don't know where to begin.Do you have any thoughts about what could possibly be wrong with you?My new patient paperwork will take you approximately 2 hours to complete, the details you provide to me will be critically important. You will be asked to complete a 3-5 page (typed up) health narrative-Your heath story. I would then review all of this information including past laboratory tests, prior to your Report of Findings. During this report (60-90 minutes) I will explain how I want to tackle your case, the kinds of tests you need, and what I feel could be potentially causing or contributing to your problems. Final Question- What is Your Health Budget. This can be the most important question when it comes to working with either myself or one of my clinical nutritionists or associates. Your financial ability will determine the kinds of testing, your treatment and how thorough of a workup I can perform. How would you describe your financial ability or budget for the testing you may require? *Less than $500$500-$1000 (Minimal Testing)$1000-$2000 (Moderate Testing)$2000-4,000 (Comprehensive Testing)Insurance company does not cover treatment or testing. After Dr. Hagmeyer reviews your questionnaire you will be contacted via email with your next steps.