• Functional Medicine Health Survey

  • Complete this functional medicine health survey before your Deep Dive Session (60 minutes) with Joud.

    The investment is 670 AED (≈130 JOD). 

    • A payment link will come as soon as you submit the form.
    • Follow the link to complete your payment.
    • Your booking link will appear immediately after you pay. Do not close the page, as you'll be redirected to schedule your session with Joud when clicking the link.
  • Date of Birth*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Today's Date*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Condition and major symptoms*
    Rows
  • Select what is applicable to you*
    Rows
  • Do you currently follow any of the following special diets or nutritional programs?*
  • Do you have sensitivities, allergies, or reactions to certain foods?*
  • Genetic predisposition: Please list medical conditions within your family’s health history *
    Rows
  •  Current Medication/Supplements *
    Rows

  • How often do you experience the following

  • Possible Low Stomach HCL *
    Rows
  • Possible Low Stomach HCL*
    Rows
  • Possible High Stomach HCL *
    Rows
  • Possible High Stomach HCL*
    Rows

  • How often do you experience the following

  • Possible Small Intestine Bacterial Overgrowth *
    Rows
  • Possible Candida*
    Rows

  • How often do you experience the following

  • Possible Heavy Metals Exposure & Environmental Chemicals *
    Rows
  • Possible Heavy Metals Exposure & Environmental Chemicals *
    Rows

  • How often do you experience the following

  • Possible Mold Exposure*
    Rows
  • Possible Mold Exposure*
    Rows

  • How often do you experience the following

  • Possible Deficiency of Nutrients*
    Rows
  • Possible Deficiency of Nutrients*
    Rows

  • How often do you experience the following

  • Possible Secondary Mitochondrial Dysfunction*
    Rows
  • Possible Secondary Mitochondrial Dysfunction*
    Rows

  • How often do you experience the following

  • Possible Low Testosterone *
    Rows
  • Possible Low Testosterone *
    Rows
  • Possible High Estrogen*
    Rows

  • How often do you experience the following

  • Possible Adrenal Hypocortisolemia *
    Rows
  • Possible Adrenal Hypocortisolemia *
    Rows

  • How often do you experience the following

  • Possible Low Thyroid or Thyroid Hormone Imbalance *
    Rows
  • Possible High Thyroid or Thyroid Hormone Imbalance*
    Rows
  • Possible Pituitary Dysfunction*
    Rows

  • How often do you experience the following

  • Possible (Low) Serotonin Imbalance *
    Rows
  • Possible Low Endorphin *
    Rows
  • Possible Low Endorphin *
    Rows
  • Possible Low Norepinephrine *
    Rows
  • Possible Low GABA *
    Rows

  • How often do you experience the following

  • Possible (Low) Dopamine Imbalance *
    Rows
  • Possible (Low) Dopamine Imbalance *
    Rows

  • Session Booking & Payment Policy

    • Session is confirmed only upon:
      • Completion of this form
      • Completion of payment
    • All payments are non-refundable
    • Sessions are non-transferable
    • Payment is valid only for the individual submitting the survey

     

  • Session Booking & Payment Policy

    • Session is confirmed only upon:
      • Completion of this form
      • Submission of proof of payment (120 JOD)
    • All payments are non-refundable
    • Sessions are non-transferable
    • Payment is valid only for the individual submitting the survey

    Payment Methods 

    CLIQ:
    INHALEJO 


    Bank Transfer: 
    Account number: 0010125903820501
    IBAN: JO74UBSI1010000010125903820501
    Swift code: UBSIJOAX
     

    Upload Requirement:
    Please upload a screenshot of your payment confirmation

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  • Contact

    For any inquiries:
    info@joudbitar.co

     

  • After you submit, you will be re-directed to the payment link, then to book your 60min one-on-one Deep Dive Session

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