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Heal With Jamie

New Client Intake Form - Customized Holistic Wellness Plan Questionnaire

Hi! I'm so glad you are here! Please take the next 20-30 minutes completing this intake form. It is a lot, I know, but it helps me create the most optimal plan geared towards your specific needs. Be as honest and thorough as possible when answering questions. After completion, you will be directed to a page to make your payment. Following your payment, you can expect to receive your customized Holistic Wellness Plan to your inbox within 10-14 business days.

The information provided in this form will be kept strictly confidential and is protected from misuse, loss or unauthorized modification, disclosure or access.

Disclaimer

I am not a medical doctor. I am not legally permitted to diagnose or treat diseases. My role is to advise you with respect to building and maintaining wellness and to give you guidance in learning how to provide your body with the nutrients needed to find its own balance.

If you have a condition requiring medical attention, it is imperative that you consult a medical doctor. Legally I am not permitted to advise you on it. My role is to help you to discover and support your unique nutritional weaknesses.

CLIENT STATEMENT

I hereby attest to the following:

• I fully understand that Jamie Shankland is not a medical doctor and I am not here for medical diagnostic or treatment procedures.

• The services provided by Jamie Shankland are at all times restricted to consultation on the subject of nutritional matters intended for general nutrition well-being and do not involve the diagnosing, treatment, or prescribing of remedies for the treatment of any disease, or any licensed or controlled act which may constitute the practice of medicine.

• This agreement is being signed voluntarily and not under duress.

• I am here on this and any subsequent visits solely on my own behalf and not as an agent for any municipal, provincial, federal, or professional agency on a mission of investigation or entrapment.

CANCELLATION POLICY (if applicable)

If you must cancel your appointment, please provide at least 24 hours notice. If you are unable to provide at least 24 hours notice when you cancel, you will be charged 50% of the session fee unless I am able to fill it with another client. The only way this fee will be waived is in the event of a serious illness or emergency or reasonable circumstance.

Payments and Refunds

Payments must be made in full before services begin unless otherwise agreed upon. Refunds are not provided for completed coaching sessions or wellness plans.

Non-Disclosure Agreement

By signing this form, the client agrees that all information, materials, and programs provided are for personal use only and shall not be duplicated, shared, or distributed for payment or any other purpose without prior written consent from the provider.

Today's Date

Sign below to acknowledge all of the above terms & conditions.

Signature

What is your first name?

Phone #

Email Address

Marital Status

Single

Married

Divorced

In a relationship

How did you find Heal with Jamie?

I know Jamie personally

Instagram

google

other

Gender

Age

Current height in Ft

Birthdate

Current weight

Goal Weight

Occupation

Does your job require a lot of physical activity?

Yes

Your current physically activity level

Sedentary

Moderate

Active

Very active

Exercise, Training & Activity Details (Include activity, duration & times per week)

Additional notes on physical activity?

Are you extremely fatigued after exercise?

What statement best describes you?

I can eat practically anything I want and I don’t gain weight.

I find it very hard to gain weight.

I can lose or gain weight by adjusting my activity level and eating habits.

I find it difficult to lose weight.

I can gain weight easily and have to watch what I eat.

Have you ever followed a nutritional program before? If yes, what worked/didn't work?

Main Health Concerns (describe symptoms & duration, it can be major or minor, be as honest as possible!)

When did your health problems first begin?

What else was going on in your life at that time? (Ex. change in diet, physical activity, job, relationships, and any additional details you remember.)

Have you ever been hospitalized? If so, when & for what?

List any surgeries you have had (if any).

Did you take the Covid-19 vaccine? If so, did you have any side effects?

What other health care practitioners do you currently see? If any. (Ex. naturopath, RMT, chiropractor, etc.)

Do you feel less vital than you did last year?

Yes

Do you like yourself as you are today?

Yes

Do you feel confident?

Yes

Sometimes

Do you believe stress is reducing your quality of life?

Yes

Do you feel your life has meaning and purpose?

Yes

Do you like the work you do?

Yes

Do you currently practice relaxation techniques? (Ex. meditation, yoga, etc.)

Yes

Have you ever been abused or experienced a significant trauma?

Yes

Do you have a good support system at home?

Yes

Do you emotional eat?

Yes

Are you happy?

Yes

If you could change one thing about yourself (emotional or physical) what would it be?

Do any moments in your life stand out as being more stressful? What moment?

What do you do to destress and relax? List, even if it is negative!

What makes you feel your best? (Ex. eating right, moving your body, sunshine, etc.)

What makes you feel your worse? (Ex. drinking, eating junk food, sitting on the couch all day, etc.)

What time do you usually go to sleep and wake up on an average day?

Do you usually feel well-rested?

Do you use sleep aids? If so, what?

Do you have children? If so, list ages.

Any recent life changes or significant losses?

What are your major stressors in your life? Select all that apply.

Please tell me about your family health history. (Parents and siblings ages, health status, significant illnesses, etc.)

Do you have any food allergies? If so, what are they?

Do you have any food sensitivities? If so, what are they?

Have you been tested for food sensitivities?

Are there any foods you will not eat under any circumstances? List below.

Are you currently following a specific type of diet? Select all that apply.

Do you grocery shop?

Yes

Do you cook your own meals?

Yes

Do you read food labels?

Yes

How many meals do you eat out per week?

0-1

2-4

5-8

9-12

12+

Have you recently changed your eating habits due to health? If so, explain.

Do you use a microwave often?

Yes

Do you use deodorant with aluminum in it?

Yes

I don't know

Do you use toothpaste with fluoride in it?

Yes

I don't know

Do you consume aspartame) (Ex. diet drinks and snacks)

Yes

Do you use aluminum or non-stick pans?

Yes

Do you use sunscreen regularly? If so, is it natural?

Do you currently eat/purchase organic foods?

Yes

Are you open to purchasing organic?

Yes

Do you consume any of these beverages daily? Select all that apply.

How many cups of water do you drink per day?

Outline a typical day of eating. (Breakfast, lunch, dinner, snacks and beverages)

Do you experience any unpleasant symptoms after meals? Explain. (Ex. bloating, gas, fatigue, etc.)

Do you use recreational drugs? If so, explain. (All answers are confidential)

Do you use Marijuana or CBD therapeutically? If so, explain

Have you ever had any side effects from taking medications? If so, explain.

List any vitamins, supplements herbs and/or prescription medications you are currently taking (include brand, dosage and reason.)

Do you smoke?

Yes

Are you exposed to second hand smoke?

Yes

Do you currently have any of the following conditions? Select all that may apply.

Women Only- do you currently experience any of the following?

Women only - Are you currently on birth control or have you been in the last five years?

Yes

Women only - Are you currently or have you recently struggled with infertility?

Yes

Review the list of symptoms below and select all that currently apply to you.

What are your top 5 health/wellness goals for our
time together? Be specific. (Ex. Weight loss, weight gain, relief from fatigue, IBS, skin health, depression, anxiety, or sleep disorders, eating for your body type, etc.) Think big picture, what do you need to fix in order to change your life?