Initial Assessment | Trainer Ryaash

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Initial Assessment & Triage Questionnaire

Sign up by completing the form below.

Full Name

Phone

In general, what are your goals? Check all that apply. * Required

Lose weight / fat

Gain weight

Maintain weight

Improve physical fitness

Look/Feel better

Have more energy and vitality

Physique competition / modeling

On average, how many hours per night do you sleep? *

4 or fewer hours

5 hours

6 hours

7 hours

8 hours

9 hours

10 hours or more

What do you usually have for your breakfast?

What do you usually have for your Dinner?

Right now, are you following any particular diet or style of eating? If yes, List:

What do you usually have for you Lunch?

What do you usually snack on?

Do you have any known / diagnosed food allergies or intolerances? If yes, what are those?

List the things you LOVE to eat or for me to include in your plan

Medical Conditions - Ears, Nose and Throat

Allergies

Hearing loss

Frequent nosebleeds

Frequent sinus trouble

Frequent hoarseness

Ringing/buzzing ears

Earaches

Medical Conditions - Neurological and cognitive

Epilepsy

Convulsions/seizures

Anxiety

Depression

Mood disorder

Trouble thinking and / or remembering

Dizziness

Frequent headaches

Tremors

Difficulty concentrating

Numbness / tingling extremities

Other mental health conditions:

Medical Conditions - Heart and circulation

Fainting or lightheadedness

Heart attack

Heart murmur

Heart valve abnormality

Angina

Heart failure

High blood pressure

Pain or discomfort in chest

Swelling of feet

Leg pain while walking

Bleeding / bruising easily

Other heart / circulation conditions:

Medical Conditions - Hormones

Thyroid conditions

Trouble controlling blood sugar

Diabetes

Sex hormone imbalance

Low or high cortisol

Other hormonal conditions

Medical Conditions - Men's Health

Prostatitis

Low testosterone

Infertility

Trouble with sexual function

Other men’s health conditions

List the things you HATE, or would like for me to nt add into you plan

Medical Conditions - Eyes and vision

Poor night vision

Change in vision

Blurred or double vision

Glaucoma

Other eye / vision conditions:

Medical Conditions - Mouth and oral health

Bleeding gums and / or sore mouth

Tooth decay

Bad breath

Other mouth / oral health conditions

Medical Conditions - Lungs and airway

Asthma

Shortness of breath

Chronic or frequent cough

Brown/blood-tinged sputum

Chest tightness

Wheezing

Other lung / airway conditions

Medical Conditions - Skin

Eczema

Psoriasis

Acne

Skin cancer

Fungal infections

Other skin-related conditions

Medical Conditions - Sleep

Sleep apnea

Snoring

Insomnia

Other sleep-related conditions

Medical Conditions - Musculoskeletal

Back trouble/pain

Neck trouble/pain

Joint injury/pain/swelling

Carpal tunnel syndrome

Other musculoskeletal conditions

Medical Conditions - Women's Health

PCOS

PMS

Infertility

Endometriosis

Painful menstruation

Hot flashes / night sweats

Other women’s health conditions

We will get back to you with your plan! Do note it might take 48-72 hours

Amin Avenue Teak

Reethigas Magu

info@ryaash.com
7515118

© 2023 by Ryaash

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