Questionnaire FORM | The Johnston Health Institute

This is Part 2 and 3 of Your 3-Part Instructions. (If you've net yet done Part 1, click Go back.)

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

AFTER PAYING FOR YOUR PAID SERVICE OR PICKING YOUR FREE SERVICE, ANSWER ALL QUESTIONS FULLY AND CLICK "SUBMIT". (This form is optional if you have scheduled a Free Zoom call with Dr. Johnston, but it is helpful as it will aid Dr. Johnston in prepping for your call.)

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

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 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?

Do you have any questions?

STEP 3 - Check your Email for an email with your Zoom link for your first appointment (Check your Spam folder if you don't see it within 24 hours.)

Please help spread the word about our services. Thank you.

This is Part 2 and 3 of Your 3-Part Instructions. (If you've net yet done Part 1, click Go back.) Fill out questionnaire fully below, and click "Submit" when you're done.

STEP 3 - Check your Email for an email with your Zoom link for your first appointment (Check your Spam folder if you don't see it within 24 hours.) Please help spread the word about our services. Thank you.

This is Part 2 and 3 of Your 3-Part Instructions. (If you've net yet done Part 1, click Go back.)

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

STEP 3 - Check your Email for an email with your Zoom link for your first appointment (Check your Spam folder if you don't see it within 24 hours.)

Please help spread the word about our services. Thank you.