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Online Forms

Jacksonville Health & Wellness Center offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our office.


  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • Fax us your printed and completed form(s) or bring it with you to your appointment.
  • NOTE: For ALL our functional medicine appointments, please call our office to gain access to our on-line portal where you will be directed and given instructions on how to complete our in-depth medical history review. This must be completed BEFORE your upcoming visit with the Doctor. The analysis will help to create a 30-page custom report for your upcoming visit -- see below "Functional Medicine (On-Line Portal). Please Note: If you complete the on-line portal history, you DO NOT have to fill out the "Functional Medicine (Paper Forms) as this option is only for patients that do not have access to a computer.

Chiropractic, Massage and/or Physical Therapy
Functional Medicine (Paper Forms). Please Note: This Option is NOT PREFERRED
Mental Health Counseling

Functional Medicine (On-Line Portal)


Child Neurotransmitter and Nutrition Questionnaire
Child Toxin Exposure Questionnaire
Metabolic Assessment Questionnaire
Depression Anxiety and Stress Questionnaire
Adult Neurotransmitter Questionnaire
Adult Toxin Exposure Questionnaire
Adult Medical Questionnaire I
Adult Medical Questionnaire II

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