PRE-CONSULTATION QUESTIONNAIRE - OC Fitness Coach : OC Fitness Coach

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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)

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

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

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

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

Describe Your Surgical History

Have You Had Any Past Injuries?

Yes

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

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

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.

SCHEDULE A FREE FITNESS EVALUATION TODAY!

(949) 829-4589

General Information

Emergency Contact Information

How Did You Learn About Us

Your Health Goals

Medical Information

Nutritional History

Weight History

Other Information

Deep Dive Symptom Questionnaire

HEAD

NOSE

MOUTH

SKIN

HEART

LUNGS

DIGESTION

JOINTS & MUSCLES

WEIGHT

ENERGY

MIND

MOOD

OTHER

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