Work with Me
About Me
My Approach
Testimonials
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Products and Services
Past Events
Forms
Gifts from Jessica
Appointments
Recipes
Blog
Contact
Jessica Ruth Shepard
Work with Me
About Me
My Approach
Testimonials
Services
Resources
Products and Services
Past Events
Forms
Gifts from Jessica
Appointments
Recipes
Blog
Contact
Get the printable version here
Printable Form
Name
*
Name
First Name
Last Name
Address
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
How often do you check email?
*
Phone Number
*
Work, cell, home
Age/Height
*
Date and Place of Birth
*
Weight
*
Current, 6 months ago, 1 year ago
Would you like your weight to be different? If yes, how so?
*
Relationship Status
*
Do you have any children? Please list:
*
Do you have any pets? Please list:
*
What is your occupation, and how many hours do you work/week?
*
Please list your main health concerns and goals.
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At what point in your life did you feel best?
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Any serious illnesses/hospitalizations/injuries?
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How is the health of your parents?
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What is your ancestry?
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What is your blood type?
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How many hours do you sleep at night?
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Do you wake up at night? If so, why?
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Any pain, stiffness or swelling?
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How is your digestion? Constipation/Diarrhea/Gas? Please explain:
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Do you have any allergies or sensitivities? Please explain:
*
Do you take any supplements or medications? Please list:
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Any healers, helpers or therapies with which you are involved? Please list:
*
What role do sports and exercise play in your life?
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What foods did you eat often as a child?
*
Breakfast, Lunch, Dinner, Snacks, Liquids
What foods make up your current diet?
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Breakfast, Lunch, Dinner, Snacks, Liquids
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
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Do you crave sugar, coffee, cigarettes, or have any major addictions?
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What percentage of your food is home-cooked? Do you cook?
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What is the source of your food that is not home-cooked?
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The most important thing I should change about my diet to improve my health is:
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Anything else you want to share?
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Thank you!