Health Assessment Form

What is your social media username if applicable? *

e.g. Instagram username.

How did you find us? *

e.g. found your social media page, a conversation via DMs, through a friend etc.

What is your body weight in kg? *

What do you do for a living?: *

What would you like to achieve over the next 6 months, if we were to work together? *

On a scale of 1-10, how much of a priority is your goal? *

10 being your fully willing to make your goal(s) a top priority

What do you think is holding you back from achieving your goals? *

Is this something you’re wanting to work on now or later on down the line? *

Have you ever been tested for Helicobacter (H. Pylori). If yes, was the result positive or negative? *

Yes

If positive, what therapy / treatment, if any, did you undergo? *

If negative, type "negative test'

Adrenal function (please tick all symptoms that apply):

Difficulty falling asleep

Difficulty waking up or getting going in the morning

History of high or low blood pressure

Grinding teeth at night

Chronic back or knee pain

Become dizzy when standing suddenly

Crave salty foods

Emotionally traumatic events in the past

Please list any more information regarding your female health if applicable. For example - type of birth control, conditions present such as PCOS etc.

If there's no further info, type "none"

Please list any more information regarding your dental health if needed. For example - total number of fillings, root canals, history etc.

If there's no further info, type "none"

Environmental factors (please tick all that apply):

Have you lived or worked in buildings with mould?

Do you NOT use a water filter for drinking?

Is there a Wi-Fi router in your bedroom?

Have you had mercury fillings?

Do you NOT stand barefoot outdoors or on cement daily?

Do you live next to power lines or industrial plants

Do you follow a specific diet outline (e.g. vegetarian, carnivore, paleo, etc)? *

How many steps do you average per day (according to an activity tracker or smart phone health tracking app)? *

Do you currently take any prescription medication? If so, what type, why, what dosages, and how long have you taken it for? (this includes any contraceptive medication). *

If not, please write "none".

Known food sensitivities or triggers?

If any

Which area(s) related to you the most? *

Wanting to understanding nutrition and my food choices to a much greater depth

Struggling with "stubborn body fat" and not able to see progress

Struggling with bloating, "IBS", depression or other negative health issues

Struggling with gut health and digestive issues

Wanting to utilise health and blood work analysis

Nothing in particular

After submitting this form, you will gain access to one hour's worth of free videos essential for preparing for your call with Jamie and improving your health and quality of life. You will be asked at the beginning of your call whether you have watched them. Prioritising this hour indicates your commitment to making real changes. Will you set aside time to view these videos? *

Yes I will make the time

No I haven't got the time

Jamie offers holistic solutions aimed at assisting his clients with their health concerns and enhancing their overall quality of life. While he tries to support as many individuals as possible, he prioritises support for those genuinely committed to transforming their lives for the better. With this in mind, could you please explain how you would like him to assist you moving forward? *

If you believed this process could address your concerns and improve your quality of life, considering Jamie’s comprehensive packages which include blood work analysis, health protocols, food intolerance assessments, personalised dietary recommendations, exercise guidance, stress management and over 30 hours of educational content. What level of commitment would you be willing and able to make right now? *

£997

£997+

I am willing to invest whatever it takes

I’m serious, but not able to invest the amounts listed upfront

I'm not willing to invest this much into my health

1 - Disclaimer: I acknowledge that Jamie Hayward (of Coach Hayward) and the Coach Hayward coaching staff cannot provide professional medical advice. Any advice given by them is not meant to diagnose, treat, or cure any dysfunction, disorder, or disease. It is solely for informational purposes and should not be used to contradict the advice of trained medical professionals. I hereby release Jamie Hayward (of Coach Hayward) and the Coach Hayward coaching staff from any injury, claim, loss, liability, or damage that may allegedly arise from the information or suggestions provided during our consultations or online coaching sessions, or from any material or content created by them. In the event of any health conditions, I will seek diagnosis and treatment from my registered healthcare practitioner. *

I have read and understood the Disclaimer terms and conditions.

I agree to the Disclaimer terms and conditions: *

Clear