Pre-Consultation Questionnaire

Welcome to your initial step towards a personalized health consultation. Please take a few moments to answer the following questions. Your responses will provide valuable insights to help us better understand your health concerns and tailor our approach to your needs.

Top Three Health Complaints
Please list your top three health complaints, with the most pressing issue first.(Required)
Successful Remedies
What treatments, lifestyle changes, or remedies have you tried in the past that have resulted in improvement of your health complaints? Please be as specific as possible.(Required)
Unsuccessful Attempts
Please share any treatments, lifestyle changes, or remedies you have tried that did not work or possibly worsened your condition(s). Again, the more details you can provide, the better.(Required)
Current Supplements and Medications
List any supplements, herbs, medications, or over-the-counter drugs you are currently taking, including dosages and frequency of use.(Required)
Additional Information
Is there anything else you feel is important for us to know about your health or lifestyle? This could include dietary restrictions, allergies, significant life stressors, or any other information you believe is relevant to your health.(Required)
Privacy and Consent
(Required)
- By checking this box, I consent to share this information with WellnessPlus for the purpose of my upcoming health consultation. I understand that my information will be used to assist in my care and treatment planning, and I affirm that the information provided is accurate to the best of my knowledge.
Signature(Required)
Date December 21, 2024
Please submit this questionnaire at least 24 hours before your scheduled appointment to allow adequate time for review.
Thank you for taking the time to complete this questionnaire. We look forward to helping you achieve your health goals.

* Our packages do not include supplements or labs. Information provided is intended for educational purposes, should not be taken as professional medical advice / used as a substitute for medical care. You agree you will consult with your personal physician when it comes to any medication, supplements and/or diet changes. You expressly agree WellnessPlus by Dr. Jess MD or its Independent Contractors shall have no liability for any damages beyond the amount of the Fee and is not responsible for any adverse effects or consequences that may result from any information provided. Due to the nature of the products and services provided, all sales are final.

Pre-Consultation Questionnaire

Top Three Health Complaints

Successful Remedies

Unsuccessful Attempts

Current Supplements and Medications

Additional Information

Privacy and Consent

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