Form Submission is restricted Form is successfully submitted. Thank you! Pre-Consultation Questionnaire General Information Health Goals Medical Information Nutritional & Physical History Deep Dive Symptom Questionnaire Complete General Information First Name* Last Name* Gender Male Female Date of Birth Street Address City State ZIP Telephone (Mobile) Email Emergency Contact Information Contact Person's Name Contact Phone Relationship to You How Did You Learn About Us Were You Referred to OC Fitness Coach? Yes No How Did You Hear About Us? Google Mailer Yelp! Other Who Referred You to OC Fitness Coach? How You Heard About Us Your Health Goals Check All That Apply Accountability Look Better Increase Flexibility Lose Weight Build Confidence Improve Nutrition Increase Muscle Mass Maintain Weight Build Strength Medical (ie. BP, Cholesterol, Diabetes, etc.) Gain Weight Other What Other Health Goals do You Have in Mind? Are there any barriers to achieving these goals? Yes No What Barriers do You Perceive with Achieving These Goals? How Important Are These Goals? (0 - No Importance, 10 - Highly Important) How Confident Are You In Reaching These Goals? (0 - No Confidence, 10 - Most Confidence) Please Check All Areas of Interest Weight Training TRX Stick Mobility Kick Boxing Self Defense HIIT (High Intensity Interval Training) Nutrition Functional Medicine Medical Information On a Scale of 1 to 10, How Would You Describe Your Health? (0 - Extremely Unhealthy, 10 - Extremely Healthy) Comments Have You Taken or Are You Taking Any Prescription Medications or Supplements? Yes No Please List Medications or Supplements and Reason for Taking When is the Last Time You Visited Your Physician? Have You Been Diagnosed with Any of the Following Conditions (Past or Present)? Allergies Diabetes Amenorrhea or absence of menstrual period > 3 months Disordered Eating Anemia High Blood Pressure / Hypertension Anxiety Gastroesophageal Reflux Disease (GERD) High Cholesterol Arthritis Hyper/Hypothyroidism Asthma Hypoglycemia Cancer Insomnia Cardiovascular Disease Intestinal Problems Celiac Disease Irritable Bowel Syndrome Chronic Sinus Condition Osteoporosis Cigarette/Tobacco User Polycystic Ovary Disease Crohn's Disease Pregnant or < 3 Months Postpartum Depression Skin Problems Please Describe Your Allergies Please Describe Your Skin Conditions Have You Had Any Surgeries? Yes No Describe Your Surgical History Have You Had Any Past Injuries? Yes No Describe Your Past Injuries Has anyone in your family been diagnosed with any of these conditions? Heart Disease High Cholesterol High Blood Pressure Cancer Diabetes Osteoporosis Other Who Was Diagnosed with Heart Disease? At What Age Was This Diagnosis For Heart Disease? Who Was Diagnosed with High Cholesterol At What Age Was This Diagnosis for High Cholesterol? Who Was Diagnosed with High Blood Pressure At What Age Was This Diagnosis for High Blood Pressure? Who Was Diagnosed with Cancer At What Age Was This Diagnosis for Cancer? Who Was Diagnosed with Diabetes At What Age Was This Diagnosis for Diabetes? Who Was Diagnosed with Osteoporosis At What Age Was This Diagnosis for Osteoporosis? Please Describe Any Other Diagnoses in Your Family At What Age Were These Diagnoses? Nutritional History Do You Follow a Specialized Diet? Yes No Please Describe Diet & Reasons for Following Who purchases and prepares your food? How many times a week do you eat out (i.e. restaurants, fast food) How many ounces of water do you drink a day (estimate)? Are You Currently Physically Active? Yes No Describe Your Physical Activity Weight History What Would You Like to Do Regarding Your Weight? Lose Weight Maintain Weight Gain Weight What was your lowest weight in the past five years? What was your highest weight in the past five years? What is your current weight? What is your height? Other Information Other Information We Should Know? Deep Dive Symptom Questionnaire Please rate any symptoms you may have experienced over the past two years HEAD Headache Never Never Rarely Sometimes Often Most of the Time Faintness Never Never Rarely Sometimes Often Most of the Time Dizziness Never Never Rarely Sometimes Often Most of the Time Insomnia Never Never Rarely Sometimes Often Most of the Time Comments & Details for Head Symptoms NOSE Stuffy Nose Never Never Rarely Sometimes Often Most of the Time Sinus Problems Never Never Rarely Sometimes Often Most of the Time Hay Fever Never Never Rarely Sometimes Often Most of the Time Sneezing Attacks Never Never Rarely Sometimes Often Most of the Time Excessive Mucus Formation Never Never Rarely Sometimes Often Most of the Time Comments or Details for Nose Symptoms MOUTH Chronic Coughing Never Never Rarely Sometimes Often Most of the Time Gagging or Frequent Need to Clear Throat Never Never Rarely Sometimes Often Most of the Time Sore Throat, Hoarseness or Loss of Voice Never Never Rarely Sometimes Often Most of the Time Swollen or Discolored Tongue, Gums or Lips Never Never Rarely Sometimes Often Most of the Time Chronic Tooth or Gum Pain or Jaw Pain (please describe) Never Never Rarely Sometimes Often Most of the Time Canker Sores Never Never Rarely Sometimes Often Most of the Time Comments or Details for Mouth Symptoms SKIN Acne Never Never Rarely Sometimes Often Most of the Time Hives or Other Allergic Breakout Never Never Rarely Sometimes Often Most of the Time Rash or Persistently Dry Skin Never Never Rarely Sometimes Often Most of the Time Hair Loss Never Never Rarely Sometimes Often Most of the Time Flushing or Hot Flashes Never Never Rarely Sometimes Often Most of the Time Frequently Feeling Cold Never Never Rarely Sometimes Often Most of the Time Excessive Sweating Never Never Rarely Sometimes Often Most of the Time Part of Body Feeling Numb (Describe Below) Never Never Rarely Sometimes Often Most of the Time Comments or Details for Skin Symptoms HEART Irregular or Skipped Heartbeat Never Never Rarely Sometimes Often Most of the Time Rapid or Pounding Heartbeat Never Never Rarely Sometimes Often Most of the Time Chest Pain Never Never Rarely Sometimes Often Most of the Time Comments or Details for Heart Symptoms LUNGS Chest Congestion Never Never Rarely Sometimes Often Most of the Time Asthma, Bronchitis Never Never Rarely Sometimes Often Most of the Time Shortness of Breath Never Never Rarely Sometimes Often Most of the Time Difficulty Breathing Never Never Rarely Sometimes Often Most of the Time Comments or Details for Lung Symptoms DIGESTION Nausea or Vomiting Never Never Rarely Sometimes Often Most of the Time Diarrhea Never Never Rarely Sometimes Often Most of the Time Bloated Feeling Never Never Rarely Sometimes Often Most of the Time Constipation Never Never Rarely Sometimes Often Most of the Time Belching, Burping Never Never Rarely Sometimes Often Most of the Time Passing Gas, Flatulence Never Never Rarely Sometimes Often Most of the Time Heartburn Never Never Rarely Sometimes Often Most of the Time Intestinal or Stomach Pain (indicate which in comments) Never Never Rarely Sometimes Often Most of the Time Other Pain In GI Tract (indicate where in comments) Never Never Rarely Sometimes Often Most of the Time Comments or Details for Digestive Symptoms JOINTS & MUSCLES Pain or Aches in Joints Never Never Rarely Sometimes Often Most of the Time Arthritis Never Never Rarely Sometimes Often Most of the Time Stiffness or Limitation of Movement Never Never Rarely Sometimes Often Most of the Time Pain or Aches in Muscles Never Never Rarely Sometimes Often Most of the Time Tremor or Restless Leg Never Never Rarely Sometimes Often Most of the Time Feeling of Weakness or Tiredness Never Never Rarely Sometimes Often Most of the Time Comments or Details for Joints & Muscles Symptoms WEIGHT Binge Eating/Drinking Never Never Rarely Sometimes Often Most of the Time Craving Certain Foods Never Never Rarely Sometimes Often Most of the Time Excessive Weight Never Never Rarely Sometimes Often Most of the Time Compulsive Eating Never Never Rarely Sometimes Often Most of the Time Water Retention Never Never Rarely Sometimes Often Most of the Time Underweight Never Never Rarely Sometimes Often Most of the Time Comments or Details for Weight Symptoms ENERGY Fatigue, Sluggishness Never Never Rarely Sometimes Often Most of the Time Apathy, Lethargy Never Never Rarely Sometimes Often Most of the Time Hyperactivity Never Never Rarely Sometimes Often Most of the Time Restlessness Never Never Rarely Sometimes Often Most of the Time MIND Poor Memory Never Never Rarely Sometimes Often Most of the Time Confusion, Poor Comprehension Never Never Rarely Sometimes Often Most of the Time Poor Concentration or Focus Never Never Rarely Sometimes Often Most of the Time Poor Physical Coordination Never Never Rarely Sometimes Often Most of the Time Difficulty in Making Decisions Never Never Rarely Sometimes Often Most of the Time Stuttering or Stammering Never Never Rarely Sometimes Often Most of the Time Learning Disabilities Never Never Rarely Sometimes Often Most of the Time MOOD Mood Swings Never Never Rarely Sometimes Often Most of the Time Anxiety, Fear, Nervousness Never Never Rarely Sometimes Often Most of the Time Anger, Irritability, Aggressiveness Never Never Rarely Sometimes Often Most of the Time Poor Physical Coordination Never Never Rarely Sometimes Often Most of the Time Depression Never Never Rarely Sometimes Often Most of the Time Other Mood Challenges (describe in comments) Never Never Rarely Sometimes Often Most of the Time OTHER Frequent Illness Never Never Rarely Sometimes Often Most of the Time Frequent or Urgent Urination Never Never Rarely Sometimes Often Most of the Time Inability to Urinate or Low Urine Flow Never Never Rarely Sometimes Often Most of the Time Low Libido or Other Sexual Dysfunction Never Never Rarely Sometimes Often Most of the Time Genital Itch or Discharge Never Never Rarely Sometimes Often Most of the Time Breast Fibroids Never Never Rarely Sometimes Often Most of the Time Painful or Tender Breasts Never Never Rarely Sometimes Often Most of the Time Uterine Fibroids Never Never Rarely Sometimes Often Most of the Time Other Symptom (Describe in Comments) Never Never Rarely Sometimes Often Most of the Time Other Symptom (Describe in Comments) Never Never Rarely Sometimes Often Most of the Time The completion of this form assists in developing a plan that best meets your needs and to help you safely achieve your goals. This information is entirely confidential - as are all your sessions. Submit
