Schedule Free Consultation

START YOUR FUNCTIONAL WELLNESS PROGRAM TODAY

Step 1: Answer the following questions to start the process.
Step 2: Then, you MUST pick a time on Dr. Jones calendar for your Initial Free Consult. [Please schedule your time with integrity].
Step 3: During the Initial Free Consult, you'll find out if you're a good candidate. If you are, he'll let you know the next steps.

Part I

First Name

Last Name

Age

Sex

Today's Date

Phone

Please list your 3 major health concerns in order of importance:

Part II

Your first step towards better health begins with this simple questionnaire. Please pick the most appropriate number for the next 10 questions. 0 as the least/never, and 3 as the most/always.

Pass large amounts of foul-smelling gas

Frequent bloating after eating

Heartburn or reflux after eating

Alternating constipation and diarrhea

Acne and unhealthy skin

Crave sweets during the day

Irritable, agitated, easily upset

Slow starter most mornings

Tired/sluggish during day

Depression/lack of motivation

Part III

Rate on a scale of 1-10 (10 being most important):

How important is it for you to resolve your health concerns?

Do you feel that you are coachable and would enjoy a health coach helping you?

Are you prepared to make the appropriate lifestyle changes that may be necessary in order to achieve your goals?

How important is it for you to address your health through diet, lifestyle and nutrition instead of masking symptoms?

Part IV

What do you hope to accomplish with functional medicine?* (click all that apply) Identify root causes of my symptoms Develop a tailored nutrition and lifestyle plan Get a second opinion on previous diagnoses Understand more about my overall health

What other treatments or strategies have you tried to address your health concerns? (Provide a brief list or description)

Are you currently prepared to invest in improving your health through functional medicine?* Yes, I'm ready to invest in my health and make a change now. I need more information on what's involved. I'm exploring options and am not ready to commit to a plan of action.

How did you hear about me or my practice? Friend or family referral Google searching Social media Other

Submit

Schedule Free Consultation

Part I

Part II

Part III

Part IV

Contact

Helpful Links