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Reboot with Jamie

Holistic Health Coach

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Reboot with Jamie

Holistic Health Coach

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Reboot with Jamie

Holistic Health Coach

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Consultation: Health History Form

Please fill this out, as detailed as possible, for your NO RISK 15 minute consultation with Jamie. After the form is submitted, you'll be able to access Jamie's calendar to book your appointment immediately.

Name *

First

Last

Email *

Your Best Phone Number *

Age *

Would you like your weight to be different? If so, what would you like it to be? *

Please list your main health concerns: *

Other concerns and/or goals? *

Describe your sleep: how it is each night, how many hours you get, and if you wake up at night. *

Describe your food intake, be as specific as possible on a normal day. *

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? *

On a scale of 1-10, how serious are you with making lifestyle changes? (10 being VERY serious)

Selected Value: 0

What else would you want to improve?

Blood Pressure
Cholesterol
Reducing Inflammation
More Energy
Restful Sleep
Relieving Aches & Pains
Sharper Memory
Healthy Hair, Skin & Nails
Bone & Joint Health
Digestive Health
Menstrual or Menopausal Symptoms
Prostate Health
Urinary Tract Health
Regulating Blood Sugar and/or Diabetes
Weight Loss
Boosting Immune System
Building Muscle
Acne Control
Relieving Eczema or Severely Dry Skin
Children's Nutrition

Disclaimer

I am not a doctor, nutritionist, or a registered dietitian. I am a Holistic Health and Wellness Coach, and the information I provide herein is based on my personal experience, and is for educational and informational purposes only. Use of this program, advice and information contained herein, or on Reboot with Jamie and website(s), is at the sole choice and risk of each reader. Please consult your health care provider before starting this or any new diet, exercise, or supplemental program. By accessing and using this website, you acknowledge and agree to our Policies and Disclosures.

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