Questionnaire FORM | The Johnston Health Institute

top of page

Screenshot 2025-12-06 at 6.36.41 PM.png

Home
Health Coaching
Webinars
Supplements
Testimonials
About Us
More

Use tab to navigate through the menu items.

Fill out questionnaire
fully below, and click "Submit" when you're done.

ANSWER ALL QUESTIONS FULLY AND CLICK "SUBMIT". Fill out at least a week before our first Health & Wellness Coaching appointment.

If you have a family physician, what is their name and city/state? (If you don't have one, type N/A.)*

First and Last Name*

Email*

Phone*

Birthday*

Month

Day

Year

Street Address*

City*

State*

Zip Code*

Describe your present symptoms and concerns in detail, including duration, severity, and progression*

What have you tried to help and did it make a difference?

What are your medical problems?*

Please list related family members and their diseases.*

What are your medicines and doses?*

What are your drug allergies and medicine side effects?*

What is your weight and height?*

What supplements do you take regularly and what doses, and for how long?

Do you have any questions?*

Start Becoming the BEST Version of Yourself Today!

The Johnston Health Institute
James Johnston, D.O.
1227 Highway 24 27 W
Midland, NC 28107, USA

Please help spread the word about our services.

Sign Up for My Email List

For Answers to the Most Common Questions, Please Read THIS Before Emailing Us

Success! Message received.

© 2025 DocJohnston Productions

bottom of page