Coach Ryan's Health Questionnaire
Answer the questions to the best of your knowledge.
First Name *
Your answer
Last Name *
Your answer
Phone *
Your answer
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Email *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Height (feet & inches) *
Your answer
Weight (lbs)
Your answer
Gender *
Lifestyle
Do you use tobacco products? *
What is your average daily stress level? *
1=Barely any stress, 10=Almost an axiety attack.
Do you drink alcohol? *
How many times per month do you have an alcoholic beverage?
Your answer
Do you drink caffeine beverages? *
What kind of caffeinated beverages do you drink?
Do you currently lift weights, participate in group fitness classes, or any kind of exercise at least 3 times per week? *
Do you sleep soundly? *
How many hours of sleep do you get? *
Do you think your diet is healthy? *
Any digestive issues? *
Explain your digestive issues.
Your answer
Do you have bowel movement every day? *
Do you urinate frequently? *
Consultation
Reason for this consultation *
Please list all symptoms/reasons. If possible, rank them in terms of importance to you
Your answer
Any additional concerns you would like to be addressed?
Your answer
What are your own lifestyle / well being targets? *
Your answer
What are your own dietary goals? *
Your answer
What are your expectations of having your own trainer/health coach? *
Your answer
Medical History
Mark all prior/current diseases affecting YOU
Current Medications
Current Medications/Prescriptions
1. Medication / Purpose / Dose / Timing of Use
Your answer
2. Medication / Purpose / Dose / Timing of Use
Your answer
3. Medication / Purpose / Dose / Timing of Use
Your answer
4. Medication / Purpose / Dose / Timing of Use
Your answer
5. Medication / Purpose / Dose / Timing of Use
Your answer
Current Supplementation
List any supplements you are currently taking
1. Supplement / Purpose / Dose / Timing of Use
Your answer
2. Supplement / Purpose / Dose / Timing of Use
Your answer
3. Supplement / Purpose / Dose / Timing of Use
Your answer
4. Supplement / Purpose / Dose / Timing of Use
Your answer
5. Supplement / Purpose / Dose / Timing of Use
Your answer
Other Current Therapies
e.g. osteopathy, acupuncture, etc
Your answer
Past Medical History
Prior Diseases
Please list all prior diseases including previous prescribed drugs
Your answer
Prior Injuries
Please list all prior injuries including previous prescribed drugs
Your answer
Prior Hospitalizations
Please list all prior hospitalisations including previous prescribed drugs
Your answer
Prior Surgeries
Please list all prior surgeries including previous prescribed drugs
Your answer
Prior Treatments
Please list all prior treatments including prescribed drugs
Your answer
Allergies
Food Allergies (Confirmed or Suspected)
Environmental Allergies (Confirmed or Suspected)
Do you have any medicine allergies? (Confirmed or Suspected)
Your answer
Do you and any food or drink difficult to digest?
Your answer
Women Only
Do you take any contraception medication?
If yes, please explain which kind
Your answer
Are you pregnant?
How many weeks are you into pregnancy?
Your answer
When is your pregnancy due?
MM
/
DD
/
YYYY
Are you breastfeeding?
Dietary Information
Food Avoided For Religious Reasons
Other Foods Avoided For Religious Reasons
Your answer
Diets Followed In The Past
Other diets followed
Please specify the diet name and when followed
Your answer
Comfort foods you eat when you're emotions are down?
Your answer
Favorite carbohydrates?
Your answer
Meats you do not like?
Your answer
Vegetables you do not like?
Your answer
Your food weakness?
Your answer
Type out your current diet
Your answer
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