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
Sports Nutrition Program Health History
Name
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First Name
Last Name
Email Address
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Best phone number to reach you:
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Age:
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Height:
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Birthdate:
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Current weight:
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Would you like your weight to be different? If so, what?
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Social Information
Relationship status:
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Where do you currently live?
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Children:
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Pets:
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Occupation:
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Hours of work per week:
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Health Information
Please list your main health concerns:
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What role do sports and exercise play in your life?
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Any serious injuries or surgeries?
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Other concerns and/or goals:
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At what point in your life did you feel your best?
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Food Information
What is your food like these days? Please list breakfast, lunch, dinner, snack, and liquid examples.
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Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
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Do you cook?
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What percentage of your food is homecooked?
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Where do you get the rest from?
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Do you crave sugar, coffee, cigarettes, or have any major addictions?
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The most important thing I should do to improve my health is:
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Additional Comments
Anything else you would like to share?
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How is your sleep?
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How many hours per night?
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Do you wake up at night? Why?
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Any pain, stiffness, or swelling?
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Any constipation, diarrhea, or gas?
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Allergies or sensitivities?
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Medical Information
Do you take any supplements or medications? Please list:
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Any healers, helpers, or therapies with which you are involved? Please list:
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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.
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5
I am open to doing things in new and different ways in order to be successful.
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I am an optimistic person.
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I am completely accountable for the results I produce.
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I am satisfied with my current career.
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I am comfortable and confident in my own body.
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Goals
One month:
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Three months:
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Six months:
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Thank you!
