All required forms are accessible via our secure Patient Portal and can be submitted quickly and easily as fillable forms. If you are a new patient, please enroll in the secure Patient Portal via the “Patient Portal” button below to access the forms. Existing patients may also access the Patient Portal with the button below. Select the “Forms” tab to access and submit your forms electronically.

Patient Portal

Check-In Form

Please Check-In no earlier than 48 hours and no later than 24 hours before your appointment. Checking in serves as your appointment confirmation, provides a pre-visit health screening, and creates the treatment plan framework for your visit. Students: Complete only #1 below. The Check-In form is located in your secure portalunder “Forms” and at AIMA Functional Medicine and you may call it to 603-718-8328 if necessary. Your visit may be cancelled or rescheduled if you are unable to complete Check-In.

Face Mask Policy:  Face masks will always be provided, and are encouraged for those that remain at the greatest risk of severe illness from respiratory infection including senior adults, people with weakened immune systems, people with chronic health conditions (such as heart disease, lung disease, diabetes, and obesity), and medically fragile individuals. Effective 4/01/2023, face masks are optional for visitors, non-infectious patients, and vaccinated staff and students, with some exceptions. Face masks will still be required in our facility:
  • For anyone with respiratory symptoms including sneezing, runny nose, or coughing
  • For anyone with respiratory infection, including COVID-19
  • For anyone who has been recently exposed to COVID-19
  • For unvaccinated staff and students
  • Annually during circulation of acute respiratory illness in New Hampshire (“cold and flu season”), within a predetermined time frame usually spanning between October-May

If you are sneezing, coughing, or have a fever, please stay home. 

Public Health and Safety:

Please sanitize your hands upon arrival. 
DO NOT ENTER THE OFFICE IF YOU HAVE THESE SYMPTOMS: Sneezing, runny nose, congestion, scratchy throat, sore throat, cough, loss of taste or smell, fever, chills, shaking with chills, fatigue, malaise, new shortness of breath or difficulty breathing, new headache, new body aches or muscle pain; new skin changes or rash, new nausea, gastrointestinal upset, abdominal pain, vomiting, or diarrhea; delirium or confusion. Please use your secure portal or call 603-718-8328 to reschedule your appointment if you have any of these symptoms. Go directly home, seek medical assistance as needed, and always call 911 for emergency.

1. Have you recently (in the last 2-4 weeks): 
– been ill with a fever, cold, or flu-like symptoms?
– had a runny nose, sneezing, or a cough?
– been around anyone sick?
– traveled to a place that is currently experiencing any type of infectious disease outbreak?

If “yes” or “maybe”, please describe.

2. What would you like to address during your visit?

– Same thing

– Something new

– Same thing and something new

– I’m not sure if you can address it, but I have additional health concerns

If “something new” or “additional health concerns”, please describe.

3. Any recent medical visits, test results, new diagnoses, procedures, vaccinations?

If “yes” or “maybe”, please describe and share/upload visit notes and documents below.

4. Any changes to your supplements, medications, or self-care routine?

If “yes” or “maybe”, please describe.

5. Any new allergies, sensitivities, or intolerances — to foods, drugs, or environmental factors?

If “yes” or “maybe”, please describe.

 

Share Documents Here:

Please keep us in the loop to optimize your care! Securely send test results, imaging reports, health summary/after visit reports from other health care providers, office visit notes, medications and supplement lists or labels, etc., via the Messages tab in your AIMA Functional Medicine Secure Portal.

Are you waitlisted for an earlier appointment?

Patients who have completed and submitted the paperwork and who are waitlisted for an earlier appointment will be given priority for earlier appointments that become available. Completing and submitting your paperwork ahead of time is evidence of investment in your own health and serves you best by allowing us adequate time for thorough review before your visit. Please enroll in or access your secure patient portal and submit your forms as soon as you can, and no later than 24 hours before your appointment.

We look forward to seeing you soon!