Form is successfully submitted. Thank you!Pre-Consultation QuestionnaireGeneral InformationHealth GoalsMedical InformationNutritional & Physical HistoryDeep Dive Symptom QuestionnaireCompleteGeneral InformationFirst Name*Last Name*GenderMaleFemaleDate of BirthStreet AddressCityStateZIPTelephone (Mobile)EmailEmergency Contact InformationContact Person's NameContact PhoneRelationship to YouHow Did You Learn About UsWere You Referred to OC Fitness Coach?YesNoHow Did You Hear About Us?GoogleMailerYelp!OtherWho Referred You to OC Fitness Coach?How You Heard About Us Your Health GoalsCheck All That ApplyAccountabilityLook BetterIncrease FlexibilityLose WeightBuild ConfidenceImprove NutritionIncrease Muscle MassMaintain WeightBuild StrengthMedical (ie. BP, Cholesterol, Diabetes, etc.)Gain WeightOtherWhat Other Health Goals do You Have in Mind?Are there any barriers to achieving these goals?YesNoWhat 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 InterestWeight TrainingTRXStick MobilityKick BoxingSelf DefenseHIIT (High Intensity Interval Training)NutritionFunctional Medicine Medical InformationOn a Scale of 1 to 10, How Would You Describe Your Health? (0 - Extremely Unhealthy, 10 - Extremely Healthy)CommentsHave You Taken or Are You Taking Any Prescription Medications or Supplements?YesNoPlease List Medications or Supplements and Reason for TakingWhen is the Last Time You Visited Your Physician?Have You Been Diagnosed with Any of the Following Conditions (Past or Present)?AllergiesDiabetesAmenorrhea or absence of menstrual period > 3 monthsDisordered EatingAnemiaHigh Blood Pressure / HypertensionAnxietyGastroesophageal Reflux Disease (GERD) High CholesterolArthritisHyper/HypothyroidismAsthmaHypoglycemiaCancerInsomniaCardiovascular DiseaseIntestinal ProblemsCeliac DiseaseIrritable Bowel SyndromeChronic Sinus ConditionOsteoporosisCigarette/Tobacco UserPolycystic Ovary DiseaseCrohn's DiseasePregnant or < 3 Months PostpartumDepressionSkin ProblemsPlease Describe Your AllergiesPlease Describe Your Skin ConditionsHave You Had Any Surgeries?YesNoDescribe Your Surgical HistoryHave You Had Any Past Injuries?YesNoDescribe Your Past InjuriesHas anyone in your family been diagnosed with any of these conditions?Heart DiseaseHigh CholesterolHigh Blood PressureCancerDiabetesOsteoporosisOtherWho Was Diagnosed with Heart Disease?At What Age Was This Diagnosis For Heart Disease?Who Was Diagnosed with High CholesterolAt What Age Was This Diagnosis for High Cholesterol?Who Was Diagnosed with High Blood PressureAt What Age Was This Diagnosis for High Blood Pressure?Who Was Diagnosed with CancerAt What Age Was This Diagnosis for Cancer?Who Was Diagnosed with DiabetesAt What Age Was This Diagnosis for Diabetes?Who Was Diagnosed with OsteoporosisAt What Age Was This Diagnosis for Osteoporosis?Please Describe Any Other Diagnoses in Your FamilyAt What Age Were These Diagnoses? Nutritional HistoryDo You Follow a Specialized Diet?YesNoPlease Describe Diet & Reasons for FollowingWho 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?YesNoDescribe Your Physical ActivityWeight HistoryWhat Would You Like to Do Regarding Your Weight?Lose WeightMaintain WeightGain WeightWhat 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 InformationOther Information We Should Know? Deep Dive Symptom QuestionnairePlease rate any symptoms you may have experienced over the past two yearsHEADHeadacheNeverRarelySometimesOftenMost of the TimeFaintnessNeverRarelySometimesOftenMost of the TimeDizzinessNeverRarelySometimesOftenMost of the TimeInsomniaNeverRarelySometimesOftenMost of the TimeComments & Details for Head SymptomsNOSEStuffy NoseNeverRarelySometimesOftenMost of the TimeSinus ProblemsNeverRarelySometimesOftenMost of the TimeHay FeverNeverRarelySometimesOftenMost of the TimeSneezing AttacksNeverRarelySometimesOftenMost of the TimeExcessive Mucus FormationNeverRarelySometimesOftenMost of the TimeComments or Details for Nose SymptomsMOUTHChronic CoughingNeverRarelySometimesOftenMost of the TimeGagging or Frequent Need to Clear ThroatNeverRarelySometimesOftenMost of the TimeSore Throat, Hoarseness or Loss of VoiceNeverRarelySometimesOftenMost of the TimeSwollen or Discolored Tongue, Gums or LipsNeverRarelySometimesOftenMost of the TimeChronic Tooth or Gum Pain or Jaw Pain (please describe)NeverRarelySometimesOftenMost of the TimeCanker SoresNeverRarelySometimesOftenMost of the TimeComments or Details for Mouth SymptomsSKINAcneNeverRarelySometimesOftenMost of the TimeHives or Other Allergic BreakoutNeverRarelySometimesOftenMost of the TimeRash or Persistently Dry SkinNeverRarelySometimesOftenMost of the TimeHair LossNeverRarelySometimesOftenMost of the TimeFlushing or Hot FlashesNeverRarelySometimesOftenMost of the TimeFrequently Feeling ColdNeverRarelySometimesOftenMost of the TimeExcessive SweatingNeverRarelySometimesOftenMost of the TimePart of Body Feeling Numb (Describe Below)NeverRarelySometimesOftenMost of the TimeComments or Details for Skin SymptomsHEARTIrregular or Skipped HeartbeatNeverRarelySometimesOftenMost of the TimeRapid or Pounding HeartbeatNeverRarelySometimesOftenMost of the TimeChest PainNeverRarelySometimesOftenMost of the TimeComments or Details for Heart SymptomsLUNGSChest CongestionNeverRarelySometimesOftenMost of the TimeAsthma, BronchitisNeverRarelySometimesOftenMost of the TimeShortness of BreathNeverRarelySometimesOftenMost of the TimeDifficulty BreathingNeverRarelySometimesOftenMost of the TimeComments or Details for Lung SymptomsDIGESTIONNausea or VomitingNeverRarelySometimesOftenMost of the TimeDiarrheaNeverRarelySometimesOftenMost of the TimeBloated FeelingNeverRarelySometimesOftenMost of the TimeConstipationNeverRarelySometimesOftenMost of the TimeBelching, BurpingNeverRarelySometimesOftenMost of the TimePassing Gas, FlatulenceNeverRarelySometimesOftenMost of the TimeHeartburnNeverRarelySometimesOftenMost of the TimeIntestinal or Stomach Pain (indicate which in comments)NeverRarelySometimesOftenMost of the TimeOther Pain In GI Tract (indicate where in comments)NeverRarelySometimesOftenMost of the TimeComments or Details for Digestive SymptomsJOINTS & MUSCLESPain or Aches in JointsNeverRarelySometimesOftenMost of the TimeArthritisNeverRarelySometimesOftenMost of the TimeStiffness or Limitation of MovementNeverRarelySometimesOftenMost of the TimePain or Aches in MusclesNeverRarelySometimesOftenMost of the TimeTremor or Restless LegNeverRarelySometimesOftenMost of the TimeFeeling of Weakness or TirednessNeverRarelySometimesOftenMost of the TimeComments or Details for Joints & Muscles SymptomsWEIGHTBinge Eating/DrinkingNeverRarelySometimesOftenMost of the TimeCraving Certain FoodsNeverRarelySometimesOftenMost of the TimeExcessive WeightNeverRarelySometimesOftenMost of the TimeCompulsive EatingNeverRarelySometimesOftenMost of the TimeWater RetentionNeverRarelySometimesOftenMost of the TimeUnderweightNeverRarelySometimesOftenMost of the TimeComments or Details for Weight SymptomsENERGYFatigue, SluggishnessNeverRarelySometimesOftenMost of the TimeApathy, LethargyNeverRarelySometimesOftenMost of the TimeHyperactivityNeverRarelySometimesOftenMost of the TimeRestlessnessNeverRarelySometimesOftenMost of the TimeMINDPoor MemoryNeverRarelySometimesOftenMost of the TimeConfusion, Poor ComprehensionNeverRarelySometimesOftenMost of the TimePoor Concentration or FocusNeverRarelySometimesOftenMost of the TimePoor Physical CoordinationNeverRarelySometimesOftenMost of the TimeDifficulty in Making DecisionsNeverRarelySometimesOftenMost of the TimeStuttering or StammeringNeverRarelySometimesOftenMost of the TimeLearning DisabilitiesNeverRarelySometimesOftenMost of the TimeMOODMood SwingsNeverRarelySometimesOftenMost of the TimeAnxiety, Fear, NervousnessNeverRarelySometimesOftenMost of the TimeAnger, Irritability, AggressivenessNeverRarelySometimesOftenMost of the TimePoor Physical CoordinationNeverRarelySometimesOftenMost of the TimeDepressionNeverRarelySometimesOftenMost of the TimeOther Mood Challenges (describe in comments)NeverRarelySometimesOftenMost of the TimeOTHERFrequent IllnessNeverRarelySometimesOftenMost of the TimeFrequent or Urgent UrinationNeverRarelySometimesOftenMost of the TimeInability to Urinate or Low Urine FlowNeverRarelySometimesOftenMost of the TimeLow Libido or Other Sexual DysfunctionNeverRarelySometimesOftenMost of the TimeGenital Itch or DischargeNeverRarelySometimesOftenMost of the TimeBreast FibroidsNeverRarelySometimesOftenMost of the TimePainful or Tender BreastsNeverRarelySometimesOftenMost of the TimeUterine FibroidsNeverRarelySometimesOftenMost of the TimeOther Symptom (Describe in Comments)NeverRarelySometimesOftenMost of the TimeOther Symptom (Describe in Comments)NeverRarelySometimesOftenMost 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
