Client Details & Medical History - OJay Health

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Personal Details & Medical Information

Thanks for signing up for coaching with OJay Health.

Please fill out this questionnaire along with the other ones on the questionnaire page

Ollie cartoon image

Please complete the form below as accurately as possible.

Personal Details

Name *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Email Address *

Phone *

Sex *

MaleFemale

Date of Birth *

Day

Month

Year

Date of birth

Weight (kg)

Height (cm)

What are your current goals both short and long term?

Occupation

Females Only

Are you pregnant?

YesNofemale only

Have you recently experienced a miscarriage or termination?

YesNofemale only

Are you currently menstruating?

YesNofemale only

Health History

Have you had any operations? *

YesNo

If yes, please provide details

Do you have any injuries? *

YesNo

If yes, please provide details

Are you currently taking any of the following?

OpiatesStimulantsHallucinogenicBenzodiazepinesCannaboidsSolventsAmphetaminesAlcoholNicotine

If yes for any of the above, please provide details

Are you currently taking any prescription medication? *

YesNo

If yes, please provide details

Are you currently taking any non-prescription medication? *

YesNo

If yes, please provide details

Do you currently take any dietary supplements? *

YesNo

If yes, please provide details

Do you suffer from any of the following muscular/skeletal conditions?

Neck painBack painRheumatismArthritisAches and painsStiff jointsHeadaches

Do you suffer from any of the following circulatory conditions?

Heart conditionsHigh blood pressureLow blood pressureFluid retentionTired legsVaricose veinsCelluliteKidney problemsCystitisCold hands and feet

Do you suffer from any of the following nervous system conditions?

SensitivitiesMigrainesTension headachesStressDepressionEpilepsy

If yes to any of the above 3 areas, please provide details

Have you ever been diagnosed with cancer? *

YesNo

If yes, please provide details

Do you suffer from any of the following?

DermatitisAcneEczemaPsoriasisAllergiesHay feverAsthma

If yes, please provide details

Are you allergic or intolerant to anything? *

YesNo

Please enter any details of intolerances or allergies

How do you feel right now? *

If you are overweight how is the majority of that weight distributed? (ie love handles, stomach, legs)

How healthy do you honestly feel? How healthy have you been in the past?

How is your sleep? (what times do you usually sleep/wake?, how is your energy when you wake? and do you wake during the night?)

Do you suffer from anxiety or depression? *

If so, how are these issues managed at the moment?

Is there anything relating to your health or requirements you would like us to be aware of?

Training

What training goals do you currently have if any?

Access to a gym

Please describe your current training facility and equipment available if we are working on your training and you're not using your current PT (send pics if it's easier)

Describe what training you have been doing the last few weeks

Final Questions

With the things you have tried in the past what has and hasn't worked for you?

Any other information?

Consent *Disclaimer: The information presented herein is in no way intended as medical advice or to serve as a substitute for medical counseling. The information should be used in conjunction with the guidance and care of your physician. Consult your physician before beginning this program as you would with any exercise and nutrition program. If you choose not to obtain the consent of your physician and/or work with your physician throughout the duration of your time consulting with Ollie Matthews Coaching you are agreeing to accept full responsibility for your actions. By accepting your comprehensive nutrition, supplementation, and exercise program, you recognize that despite all precautions on the part of Ollie Matthews Coaching there are risks of injury or illness which can occur because of your use of the aforementioned information and you expressly assume such risks and waive, relinquish and release any claim which you may have against Ollie Matthews Coaching, or its affiliates as a result of any future physical injury or illness incurred in connection with, or as a result of, the use or misuse of your program. So in reality, let's have some fun with the training, get your health to real great levels and enjoy food whilst we're doing it, cool?

Get In Touch

Take the first step towards a healthier, happier you by joining OJay Health now.

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ollie@ojayhealth.com

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