Coach Ryan's Health Questionnaire
Answer the questions to the best of your knowledge.
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First Name *
Last Name *
Phone *
City *
Zip Code *
Email *
Date of Birth *
MM
/
DD
/
YYYY
Height (feet & inches) *
Weight (lbs)
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?
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.
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
Any additional concerns you would like to be addressed?
What are your own lifestyle / well being targets? *
What are your own dietary goals? *
What are your expectations of having your own trainer/health coach? *
Medical History
Mark all prior/current diseases affecting YOU
Current Medications
Current Medications/Prescriptions
1. Medication / Purpose / Dose / Timing of Use
2. Medication / Purpose / Dose / Timing of Use
3. Medication / Purpose / Dose / Timing of Use
4. Medication / Purpose / Dose / Timing of Use
5. Medication / Purpose / Dose / Timing of Use
Current Supplementation
List any supplements you are currently taking
1. Supplement / Purpose / Dose / Timing of Use
2. Supplement / Purpose / Dose / Timing of Use
3. Supplement / Purpose / Dose / Timing of Use
4. Supplement / Purpose / Dose / Timing of Use
5. Supplement / Purpose / Dose / Timing of Use
Other Current Therapies
e.g. osteopathy, acupuncture, etc
Past Medical History
Prior Diseases
Please list all prior diseases including previous prescribed drugs
Prior Injuries
Please list all prior injuries including previous prescribed drugs
Prior Hospitalizations
Please list all prior hospitalisations including previous prescribed drugs
Prior Surgeries
Please list all prior surgeries including previous prescribed drugs
Prior Treatments
Please list all prior treatments including prescribed drugs
Allergies
Food Allergies (Confirmed or Suspected)
Environmental Allergies (Confirmed or Suspected)
Do you have any medicine allergies? (Confirmed or Suspected)
Do you and any food or drink difficult to digest?
Women Only
Do you take any contraception medication?
If yes, please explain which kind
Are you pregnant?
Clear selection
How many weeks are you into pregnancy?
When is your pregnancy due?
MM
/
DD
/
YYYY
Are you breastfeeding?
Clear selection
Dietary Information
Food Avoided For Religious Reasons
Clear selection
Other Foods Avoided For Religious Reasons
Diets Followed In The Past
Other diets followed
Please specify the diet name and when followed
Comfort foods you eat when you're emotions are down?
Favorite carbohydrates?
Meats you do not like?
Vegetables you do not like?
Your food weakness?
Type out your current diet
Submit
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