Sample Forms & Questionnaires

Below are a selection of the forms that we have created and that you may choose to ask patients to complete and submit via the Patient Portal. Many of these forms are variations on the same questions or topics. For patients convenience, it is highly recommended that you select just a few intake questionnaires (up to 5 or so maximum), and be selective about additional forms and questionnaires. Having too many, or highly duplicative, forms available tends to be a source of confusion and frustration for patients.

If you are interested in including one or more of these questionnaires on your patient portal, please check the boxes next to the questionnaires you are interested in. Once you are done, specify any modifications/tweaks in the field at the bottom of this page and then hit submit.

Some of these forms will auto-populate the patient's chart (indicated below), while the remainder will save as a document attached to the patient's chart

Questionnaires that populate the patient's chart

The below forms push data to patients charts; once the questionnaire is accepted in Cerbo the patient’s answers will populate the corresponding block in their chart.

Medical History Questionnaires- Answers populate the Past Medical History (free-text) block.

Medical History Questionnaire - Version 1

Medical History Questionnaire - Version 2

Family History Questionnaires - Answers populate the Social/Family History block (or Family tab of the block if you have that set up)

Family History Questionnaire - Version 1

Social History Questionnaires - Answers populate the Social/Family History block (or Social tab of the block if you have that set up)

Social History Questionnaire - Version 1

Social History Questionnaire - Version 2

Symptom Questionnaires - Answers populate the Past Medical History (free-text) block

Medical Symptom/Toxicity Questionnaire

Symptom Review Questionnaire

Review of Systems

Health Action Plan - Current goals populate the Need to Know block. Past/current medical problems and surgeries populate the PMH (free text) block. Substance use and social factors populate Social/Family block.

Health Action Plan Questionnaire

Medical History Questionnaires

The Health Journey questionnaire covers less medical history details than the others but does includes some social history questions.

Health Journey: Comprehensive Case Review

Medical History Questionnaire - Version 3

Family History Questionnaires

Family History Questionnaire - Version 2

Family History Questionnaire - Version 3

Social History Questionnaires

Gender Identity and Sexual Orientation Questionnaire

Readiness Questionnaires

Readiness Assessment

Specialized Symptom Questionnaires

Biotoxin Illness Survey

Brief Pain Questionnaire

Covid-19 Screening

Digestion Questionnaire

Food and Yeast Allergy Questions

Hormone Questionnaire

Pain and Dysfunction Intake

Pain Questionnaire (Short-form McGill)

Environmental Exposure Questionnaires

Toxic Exposure Questionnaire

Environmental Exposure Questionnaire

Mold Screening

Lyme Questionnaires

Version 1 generates a score based on the patient's responses.

Lyme Symptom Questionnaire - Version 1 (Horowitz MSIDS)

Lyme Symptom Questionnaire - Version 2

Lyme Symptom Questionnaire - Version 3

Male/Female Questionnaires

Women's Questionnaire

Postmen/Perimenopausal Questionnaire

Men's Questionnaire

Pediatric Questionnaires

The long form covers everything that the short form covers, plus more. The Symptom Review Part 1 covers social/emotional issues while Part 2 focuses on physical symptoms.

Pediatric Medical History (short form)

Pediatric Medical History (long form)

Pediatric Intake Form

Pediatric Symptom Review 1

Pediatric Symptom Review 2

Two Part Comprehensive Pediatric Questionnaires

Pediatric Intake Part 1

Pediatric Intake Part 2

Diet Questionnaires

Food Survey

3-Day Diet Diary

Mental State Questionnaires

PHQ-9 Questionnaire (Depression)

Becks Depression Questionnaire

Mood Disorder Form

GAD-7 Questionnaire (Anxiety)

PC PTSD-5 (PTSD)

Memory Questionnaire

HPA AXIS Questionnaire

Hamilton Depression Rating Scale

Depression Anxiety Stress Scales

Alzheimers Questionnaire (AQ-21)

Yale-Brown Obsessive Compulsive Scale (Y-BOCS)

Other Questionnaires and Assessments

ACE Score

Adrenal Questionnaire

Blood Sugar and Insulin Resistance Questionnaire

DISC Communication Styles

Follow-Up Questionnaire

Insomnia Questionnaire

Metabolic Assessment Form

Neurotransmitter Assessment Form

Parasite Questionnaire

Thyroid Questionnaire

Consents

Note: You are required by law to have some version of the HIPAA form by the Health Insurance Portability and Accountability Act. For more information and guidelines, visit Model Notices of Privacy Practices.

Authorization to Release Medical Records

Authorization to Release Medical Records (Texas)

General Consent Form

HIPAA Model Notice of Privacy Practices (from HHS.gov)

Medicare Private Contract

Telehealth Consent Form

Other Legal Forms

Although we make some basic HIPAA and privacy forms available, it is generally left to the practice to provide the specific legal terms/contracts you'd like us to post. If you're a practice providing functional medicine services, we recommend checking out Functional Lawyer to get assistance with these resources. If you use the promo-code cerbo at check-out you'll receive a %15 discount on their services.

FunctionalLawyer.com is a medical-legal website that helps functional medicine practitioners protect their license and their business while saving thousands of dollars in legal fees. Practitioners can purchase and download customizable legal documents written by a team of expert functional medicine attorneys. The Functional Lawyer documents are written specifically for the unique needs of functional medicine providers, with documents available in four main categories: Office Essentials, HIPAA, Employment, and Websites. Created by a functional medicine practice co-owner and attorney, Functional Lawyer eliminates uncertainty and provides peace of mind so you can practice with confidence.

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Request Forms

Please be sure that you have checked every questionnaire that you want added to your Patient Portal. If you require additional forms not seen here, or if you require extensive modification to any of the above questionnaires, please contact support@md-hq.com.
What is your name?
Which Practice are you with?
What is your email address?*

*We will use this to contact you if we have any questions, as well as notify you once the forms have been posted to your Portal.

Specify any minor modifications or tweaks you would like to see. Please be as specific as possible.
Contact Cerbo Technical Support
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