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.
Start
Medical History Questionnaire - Version 1 (Group 3)
Start
Medical History Questionnaire - Version 2 (Group 4)
Family History Questionnaires - Answers populate the Social/Family History block (or Family tab of the block if you have that set up)
Start
Family History Questionnaire - Version 1 (Group 3)
Social History Questionnaires - Answers populate the Social/Family History block (or Social tab of the block if you have that set up)
Start
Social History Questionnaire - Version 1 (Group 3)
Start
Social History Questionnaire - Version 2 (Group 4)
Symptom Questionnaires - Answers populate the Past Medical History (free-text) block
Start
Medical Symptom/Toxicity Questionnaire
Start
Symptom Review Questionnaire
Start
Review of Systems (Group 4)
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.
Start
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.
Start
Health Journey: Comprehensive Case Review
Start
Direct Primary Care Intake (Other Good Forms)
Start
Medical History Questionnaire - Version 3 (General)
Start
Symptom Review Questionnaire (General)
Family History Questionnaires
Start
Family History Questionnaire - Version 2 (Group 4)
Start
Family History Questionnaire - Version 3 (Other Good Forms)
Social History Questionnaires
Start
Gender Identity and Sexual Orientation Questionnaire
Start
Social History Questionnaire
Readiness Questionnaires
Start
Readiness Assessment
COVID Questionnaires
Start
COVID-19 Screening Questionnaire
Start
Covid-19 Screening
Start
Health Questionnaire and Certification
Specialized Symptom Questionnaires
Start
Biotoxin Illness Survey
Start
Brief Pain Questionnaire
Start
Digestion Questionnaire
Start
Food and Yeast Allergy Questions
Start
Hormone Questionnaire
Start
Pain and Dysfunction Intake
Start
Pain Questionnaire (Short-form McGill)
Start
Short Inflammatory Bowel Disease (IBD) Questionnaire
Environmental Exposure Questionnaires
Start
Toxic Exposure Questionnaire
Start
Environmental Exposure Questionnaire
Start
Mold Screening
Lyme Questionnaires
Version 1 generates a score based on the patient's responses.
Start
Lyme Symptom Questionnaire - Version 1 (Horowitz MSIDS) (Group 2 - Intake)
Start
Lyme Symptom Questionnaire - Version 2 (Group 2 - Symptoms)
Start
Lyme Symptom Questionnaire - Version 3 (Group 4)
Male/Female Questionnaires
Start
Women's Questionnaire
Start
Postmen/Perimenopausal Questionnaire
Start
Adam Questionnaire
Start
Men's Questionnaire
Start
International Prostate Symptom Score I-PSS
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.
Start
Pediatric Medical History (short form)
Start
Pediatric Medical History (long form)
Start
Pediatric Intake Form
Start
Pediatric Symptom Review 1
Start
Pediatric Symptom Review 2
Two Part Comprehensive Pediatric Questionnaires
Start
Pediatric Intake Part 1
Start
Pediatric Intake Part 2
Breastfeeding Questionnaires
Start
Prenatal Visit
Start
Initial Visit: Baby's History
Start
Initial Visit: Mother's History
Start
Follow-up Visit
Diet Questionnaires
Start
Food Survey
Start
3-Day Diet Diary
Mental State Questionnaires
Start
PHQ-9 Questionnaire (Depression)
Start
Becks Depression Questionnaire
Start
Mood Disorder Form
Start
GAD-7 Questionnaire (Anxiety)
Start
PC PTSD-5 (PTSD)
Start
Memory Questionnaire
Start
Depression Anxiety Stress Scales
Start
Alzheimers Questionnaire (AQ-21)
Start
Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
Start
Edinburgh Postnatal Depression Scale
Start
Screen for Child Anxiety Related Disorders (SCARED) - Parent Version
Start
Screen for Child Anxiety Related Disorders (SCARED) - Child Version
Start
PCL-5
ADHD Questionnaires
Start
Vanderbilt ADHD Diagnostic Scale - Parent Initial
Start
Vanderbilt ADHD Diagnostic Scale - Parent Follow Up
Other Questionnaires and Assessments
Start
ACE Score
Start
Adrenal Questionnaire
Start
Blood Sugar and Insulin Resistance Questionnaire
Start
DISC Communication Styles
Start
Follow-Up Questionnaire
Start
Insomnia Questionnaire
Start
Metabolic Assessment Form
Start
Neurotransmitter Assessment Form
Start
Parasite Questionnaire
Start
Thyroid Questionnaire
Start
HPA AXIS Questionnaire
Start
STOP-BANG Sleep Apnea 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 .
Start
Authorization to Release Medical Records
Start
Authorization to Release Medical Records (Texas)
Start
General Consent Form
Start
HIPAA Model Notice of Privacy Practices (from HHS.gov )
Start
Medical Records Access Permission Form
Start
Medicare Private Contract
Start
Telehealth Consent Form
Start
Consent for Hormone Replacement Therapy in Women
Spanish Language Forms
Start Aviso de Prácticas de Privacidad y Autorización (HIPAA Privacy Practices Consent)
Start Historia Medica del Paciente (Medical History/Intake Form)
Start Cuestionario de sintomas medicos (Medical Symptom Questionnaire/MSQ)
Start Consentimiento del Paciente (Patient Consent)
Start Consentimiento de Procedimiento (Procedure Consent)
Physical Therapy
Start
Shoulder Pain and Disability Index - SPADI
Start
Optimal Instrument - Difficulty
Start
Lysholm Knee Scoring Scale
Start
Disabilities of the Arm, Shoulder, and Hand Questionnaire
Start
Dizziness Handicap Inventory
Start
Lower Extremity Functional Scale
Start
Neck Disability Index
Start
Oswestry Low Back Pain Questionnaire
Start
Patient Personal Injury History
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 5% 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.
More Info