Emma Ryan
About
Coaching
Online Programs
Events
Recipes
Lifestyle
Work with me
About
Coaching
Online Programs
Events
Recipes
Lifestyle
Emma Ryan
Integrative nutrition health coach & Raw food chef. Emma Ryan started with a passion for food that grew into a passion for changing people's stories.
Work with me
Pre-Cleanse Survey
Name
*
First Name
Last Name
Email Address
*
Best phone number to reach you:
*
Age:
*
Height:
*
Birthdate:
*
Current weight:
*
Would you like your weight to be different? If so, what?
*
Social Information
Relationship status:
*
Where do you currently live?
*
Children:
*
Pets:
*
Occupation:
*
Hours of work per week:
*
Health Information
Please list your main health concerns:
*
What role do sports and exercise play in your life?
*
Any serious injuries or surgeries?
*
Other concerns and/or goals:
*
At what point in your life did you feel your best?
*
Food Information
What is your food like these days? Please list breakfast, lunch, dinner, snack, and liquid examples.
*
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
*
Do you cook?
*
What percentage of your food is homecooked?
*
Where do you get the rest from?
*
Do you crave sugar, coffee, cigarettes, or have any major addictions?
*
The most important thing I should do to improve my health is:
*
Additional Comments
Anything else you would like to share?
*
How is your sleep?
*
How many hours per night?
*
Do you wake up at night? Why?
*
Any pain, stiffness, or swelling?
*
Any constipation, diarrhea, or gas?
*
Allergies or sensitivities?
*
Medical Information
Do you take any supplements or medications? Please list:
*
Any healers, helpers, or therapies with which you are involved? Please list:
*
Personal development and coachability
Please rate yourself on a scale of one to five (1=disagree to 5=strongly agree) on each of the following statements.
I believe I am capable of living the life I truly desire.
*
1
2
3
4
5
I am open to doing things in new and different ways in order to be successful.
*
1
2
3
4
5
I am an optimistic person.
*
1
2
3
4
5
I am completely accountable for the results I produce.
*
1
2
3
4
5
I am satisfied with my current career.
*
1
2
3
4
5
I am comfortable and confident in my own body.
*
1
2
3
4
5
Goals
One month:
*
Three months:
*
Six months:
*
Thank you!
