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
Client Health History
Personal Information
Name
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First Name
Last Name
Email Address
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How often do you check email?
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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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Place of Birth:
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Current weight:
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Weight six months ago:
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Weight one year ago:
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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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Other concerns and/or goals:
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At what point in your life did you feel your best?
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Any serious injuries/illnesses/hospitalizations?
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Food Information
What foods did you often eat as a child?
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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/was the health of your mother?
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How is/was the health of your father?
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What is your ancestry?
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What blood type are you?
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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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Women's Health
Are your periods regular?
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How many days is your flow? And how frequent?
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Painful or symptomatic periods?
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Please explain:
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Reached or approaching menopause?
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Birth control history:
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Do you experience yeast infections or urinary tract infections?
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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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What role do sports and exercise play in your life?
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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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1
2
3
4
5
I am open to doing things in new and different ways in order to be successful.
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1
2
3
4
5
I am an optimistic person.
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1
2
3
4
5
I am completely accountable for the results I produce.
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1
2
3
4
5
I am satisfied with my current career.
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1
2
3
4
5
I am comfortable and confident in my own body.
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1
2
3
4
5
Goals
To help us both clarify what health goals or concerns you want to address during your program, please take a few moments to fill in the following and bring it to your first session. Please write three goals for each time period.
One month:
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Three months:
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Six months:
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Availability
Should you become a client, we will meet on the same day, at the same time, every other week. Which days work best for you?
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Please list what time works best for you each day:
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Additional availability notes:
Thank you!
