Services
Uncovering the Magic in your Life : Rise into your Prime
Holistic Health Consult
Customized 1:1 Program
Business Mentorship
Discovery Call
About
Resources
Contact
Client Portal
Jessica Ruth Shepard
Services
Uncovering the Magic in your Life : Rise into your Prime
Holistic Health Consult
Customized 1:1 Program
Business Mentorship
Discovery Call
About
Resources
Contact
Client Portal
Get the printable version here
Printable Form
Name
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First Name
Last Name
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
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How often do you check email?
*
Phone Number
*
Work, cell, home
Age/Height
*
Date and Place of Birth
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Weight
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Current, 6 months ago, 1 year ago
Would you like your weight to be different? If yes, how so and why is this feeling important to you now?
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Relationship Status
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Do you have any children? Please list:
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Do you have any pets? Please list:
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What is your occupation, and how many hours do you work/week?
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Please list your main life and/or 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 blood type are you?
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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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Are your periods regular? What is their duration and frequency? Are they painful or symptomatic? Please explain:
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Have you reached or are you approaching menopause? Please explain:
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Birth control history:
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Do you experience yeast infections or urinary tract infections? Please explain:
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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:
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Do you take any supplements or medications? Please list details:
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Any healers, helpers or therapies with which you are involved? Please list:
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What role do sports and exercise play in your life?
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What foods did you eat often as a child?
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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 lifestyle (and/or food) changes?
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What percentage of your food is home cooked? Do you cook?
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Is socializing and/or dining out a part of your life?
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Do you crave sugar, coffee, cigarettes, or have any major addictions?
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The most important thing I think I would like to change in my life and/or health is.... (and by doing this what do I believe is possible for me)?
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Anything else you want to share?
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Thank you!
