Spotlight Session (starting point)

We are thrilled to help "spotlight" your story and better understand your health and wellness goals.  It's the beginning of the enrollment process for our practice. This questionnaire is done prior to our 20-minute Zoom call Spotlight Session (**For children/adolescents, I ask that a parent/guardian fill this out on behalf of their child). 

During our 20-minute Spotlight Session, we’ll ask specific questions to determine if functional and lifestyle medicine may be helpful for you.  If we believe we have the right tools to help, you'll be invited to make an initial appointment for a full new patient consultation. 

Our functional and lifestyle medicine practice is very unique and innovative.  It's less of a "doctor's visit" and more of a guided partnership to "illuminate" your path to better health.  Therefore, we collaborate with patients that are ready to take a different approach to reach their health goals.  This will include lifestyle modifications in addition to other root-cause approaches to improve quality of life and wellbeing.

When you schedule a Spotlight Session, there is a $10 fee that is donated to one of our local Fayette County charities (currently supporting Midwest Food Bank, Wellspring Living, Fayette Pregnancy Resource Center, and Healing Bridge Clinic).


With love + light,

Dr. Franklin and the Illuminate team


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Email *
FIRST and LAST name of person completing this form *

FIRST and LAST name of patient


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Phone Number (best contact)


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Patient's date of birth: *
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I am a resident of

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What is your zip code?

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Who is your primary care physician? *

In brief, for what top 3 medical struggles/symptoms are you seeking help? Please limit to one sentence each.


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If those symptoms disappear, what would you be free to do differently now? 


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What have you tried that has worked well so far? 

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What have you already tried that hasn’t helped? 

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Why do you feel a comprehensive, functional medical approach is right for you, and why is now the right time? 


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I do not participate in medical/legal cases, like DOT physicals, workers comp, injury cases, or vaccination waivers. Are you seeking my services for this purpose?


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Do you enjoy alcohol (wine liquor, beer)? 

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Are you a current nicotine user (vaping, cigarettes or tobacco, chew, etc)?


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Functional medicine treatment plans require consistent participation. For example, learning about your body and building new habits that may involve eating, movement, sleep, mindset, etc.).  HOW MOTIVATED are you to WORK HARD on yourself to feel better? (Choose one)
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What’s one question that you want to make sure is discussed during our phone strategy session? (Is there anything specific you are seeking?) 

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This is a high tech, high touch medical practice. People must be comfortable using computers. Please check all that apply for you: (check all that apply)

How did you hear about my services, choose one 

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Please list the referrals name below (if Applicable)
If you're ready to skip the informational Spotlight Session and proceed directly to a consultation, simply text 678-210-1956 or email info@illuminatemed.com with the following message: "My name is ____________. I have filled out the spotlight form and would like to receive the listing of your package options. I am ready to schedule a New Patient consultation through the Patient Portal registration link. Here is my email address: ___________."
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A copy of your responses will be emailed to the address you provided.
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