Contact 1 — Jade Body and Soul

HEALTH FORM

Please complete this form to the best of your abillity. If you have more than one person in your family working with Jade, each person must complete the form. Be honest and thorough.

Name

First Name

Last Name

Best Number to Call You On?

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Where do you live?

Age

Height

Birthday

Place of Birth

Current Weight

Weight Six Months Ago

Weight 12 Months Ago

Relationship Status

Where Do You Live?

How Many Children to You Have?

How Many Pets Do You Have?

Occupation?

How Many Hours Do You Work Each Week?

Describe Your Main Health Concerns

Other Conerns or Goals?

At What Point in Your Life Did You Feel Best?

Any Serious Illnesses/Hospitalizations/Injuries?

How Is/Was the Health of Your Mother?

How Is/Was the Health of Your Father?

What is Your Ancestry?

How Do You Sleep?

How Many Hours Per Night?

Do You Wake Up at Night? If Yes, Why?

Any Pain, Stiffness, or Swelling?

Constipation/Diarrhea/Gas?

Describe Any Allergies or Sensitivities?

If Applicable: Are Your Periods Regular?

If Applicable: How Many Days is Your Flow?

If Applicable: Painful or Symptomatic?

If Applicable: Reached or Approaching Menopause? Please Explain

If Applicable: Birth Control History?

Do You Experience Yeast Infections or UTIs? Please Explain:

Do You Take Any Supplements or Medications? Please List.

Any Healers, Helpers, or Therapies with Which You are Involved? Please List.

What Role Do Sports and Exercise Play in Your Life?

What Breakfast Foods Did You Eat Often as a Child?

What Lunch Foods Did You Eat Often as a Child?

What Dinner Foods Did You Eat Often as a Child?

What Breakfast Foods Do You Eat Often Now?

What Lunch Foods Do You Eat Often Now?

What Dinner Foods Do You Eat Often Now?

What Snack Foods Do You Eat Often Now?

Will Family and/or Friends be Supportive of Your Desire to Make Food and/or Lifestyle Changes?

Do You Cook?

What % of Your Food is Home-Cooked?

Where Does the Rest Come From?

Have you worked with a health coach before? Yes or no? If yes, for how long?

What Do You Crave? Sugar, Coffee, Cigarettes?

The Most Important Thing You Should Do to Improve Your Health is...

Optional: Anything Else You Wish to Share?