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Question 1 of 35
Name
Question 2 of 35
Select all areas affected by the issues listed below. Nothing is too small or too old to matter. Use the diagram above for visual reference.
• Areas of acute or chronic pain
• Scars
• Tattoos
• Accidents
• Breaks/Sprains
• Dental Work
• Pregnancies
• Head Trauma
Right Side of Face
Left Side of Face
Neck (front)
Clavicle (right)
Clavicle (left)
Ribs (right)
Ribs (left)
Abdomen (right)
Abdomen (left)
Right Hip
Left Hip
Groin
Bicep (right)
Forearm (front/right)
Right Hand (palm)
Bicep (left)
Forearm (front/left)
Left Hand (palm)
Right Thigh (front)
Right Knee (front)
Right Shin
Right Ankle
Right Foot (top)
Left Thigh (front)
Left Knee (front)
Left Shin
Left Ankle
Left Foot (top)
Left Side of Head
Right Side of Head
Back of Head (Left)
Back of Head (right)
Neck (back)
Left Shoulder (back)
Right Shoulder (back)
Upper Back (left)
Upper Back (right)
Low Back (left)
Low Back (right)
Left Glute
Right Glute
Tricep (left)
Forearm (back/left)
Left Hand (back)
Tricep (right)
Forearm (back/right)
Right Hand (back)
Left Hamstring
Left Knee (back)
Left Calf
Left Heel
Left Foot (bottom)
Right Hamstring
Right Knee (back)
Right Calf
Right Heel
Right Foot (bottom)
Question 3 of 35
Please describe issues here.
(Ex. 2013, broke left hand and chronic aching, suture scars.)
Question 4 of 35
Do you wear corrective lenses? If so, please describe correction.
Question 5 of 35
Have you had corrective optical surgery? If so, please describe.
Question 6 of 35
Have you had any major life changes in the last 6-12 months?
Question 7 of 35
Please check those that apply.
Shortness of Breath
Difficulty Focusing
Fatigue
PMS
Anxiety
Depression
PTS
Dizziness
Vertigo
Tinnitus
Headaches
Insomnia
Heart Disease
Blood Pressure
Chest Pain
Asthma / Lung Disease
Thyroid Issue
High Cholesterol
Cancer
Allergies
Other
Question 8 of 35
If "Other," please describe.
Question 10 of 35
Please list all medications that you are currently taking and their purpose/diagnosis.
(Include over the counter, prescription, and vitamin supplements.)
Question 11 of 35
Give me a bird's eye view on your current nutrition.
(What, when, how do you eat?)
Question 12 of 35
How would you describe your relationship with food?
Question 14 of 35
What were your favorite activities as a child?
Question 15 of 35
What is your favorite physical activity today?
Question 16 of 35
What kind of strength, conditioning, or rehab exercises are you currently doing? (Detailed please!)
Question 17 of 35
What barriers do you feel you need to overcome in order to be as healthy and strong as you can be?
Question 19 of 35
Profession and average work hours per week
Question 20 of 35
On average, how many hours do you sleep each night?
Question 21 of 35
What do you do to relax/reduce stress? How often do you do this?
Question 22 of 35
Do you/have you used tobacco?
Yes, I currently use tobacco.
Yes, I have used tobacco in the past.
No, I do not/have not used tobacco.
Question 23 of 35
How many alcoholic beverages do you consume per week, on average?
Question 24 of 35
How would you rate your stress level, overall? (With 0 being none and 10 extremely high.)
0 (none)
1
2
3
4
5
6
7
8
9
10 (extremely high)
Question 26 of 35
PHYSICAL HEALTH
Where are you going? What is your big, glowing dream? (Be specific.)
Question 27 of 35
What are 3 specific/measurable benchmarks that would indicate you've accomplished that dream?
Question 28 of 35
How do you feel about your journey toward those dreams? (1 being not satisfied at all, 10 being completely satisfied.)
1 (Not satisfied at all)
10 (completely satisfied)
Question 29 of 35
What habit do you feel is currently creating your trajectory?
Question 30 of 35
What support or change do you need in place that you have control over? (e.g. change in environment, social support, professional help, etc.)
Question 31 of 35
On a weekly or monthly basis, I'll know I'm on the right path if:
Question 32 of 35
Have you worked with a coach before? What worked for you? What didn't work for you?
Question 33 of 35
What would you like me to know that I haven't asked?
Question 34 of 35
I give my permission for my before/after photos and videos to be used in promotional materials.
Yes
No
Question 35 of 35
This form has been completed to the best of my knowledge and I will inform my coach of continuing health and lifestyle updates.
(Type your name.)