First Name *

Last Name *

Phone *

Email *

Street Address

City

State

Country

Postal code

Date of birth *

Height (cm) *

Weight (kg) *

Your reason for booking a consultation with Dr Jens Gudmundsson? *

Health History

Family History

Do any of your close family members have a history of chronic conditions? (e.g., diabetes, heart disease, autoimmune disorders, cancer)

Medications & Supplements

List any medications or supplements you are currently taking, including dosage and frequency: (e.g., Metformin 500mg, 1x daily; Vitamin D 1000 IU)

Symptoms

What symptoms are you currently experiencing? (e.g., fatigue, headaches, joint pain, digestive issues, etc.) *

How long have you been experiencing these symptoms? (eg., 2 weeks, 6 months). *

Lifestyle Factors

Diet: How would you describe your diet? (e.g., vegetarian, standard, low-carb, gluten-free) *

Exercise: How often do you exercise? (e.g., daily, 3x per week, rarely) *

Sleep: How many hours of sleep do you typically get per night? (e.g., 7-8 hours) *

Stress: How would you rate your stress levels? (Low, Moderate, High) *

Expectations & Goals

What do you hope to achieve from working with Dr Jens? (e.g., pain relief, managing a chronic condition, improving overall health) *

Is there anything else you’d like Dr Jens to know before your consultation?

I agree to both the Terms & Conditions and Medical Disclaimer provided by Dr Jens Gudmundsson and by checking this box, I acknowledge that I have read both and am happy to proceed.

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