Onboarding Form

1Personal Information

2Breathing

3Nutrition

4Energy & Mood

5Movement & Fitness

6Bowel Health

7Work & Life

8Medical Health

9Conclusion & Submit

Personal Information

Name *

First

Last

Age *

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

BOLT Score *

Main Health Goals

Please describe in detail the health and wellness transformation you wish to achieve during our health Coaching relationship. *

Describe any previous habits or patterns that continue to plague your health and wellness goals. What other diets, programs or alternative approaches have you attempted in the past and what were the results? Preferences? *

Describe the confidence in your ability to transform your health. *

What support for this transformation do you have at home, work and life to succeed in this program? *

What roadblocks do you anticipate will stall or prevent your success? What aspects of home, work and life have previously prevented your ability to reach your health and wellness objectives? *

What hobbies, interests, passions, games, sports, dance… do you participate in or maybe used to? *

Please share any relevant information that you think may impact your level of commitment to the program and process. What will motivate you to keep going especially when it gets a little uncomfortable? *

Breathing

Daily Occupation *

Does it require much talking or physical exertion? *

If 'Yes', please elaborate: *

Please give additional details if appropriate

Breathing - Scale *

	Never	Sometimes	Often	Very Often
Are you stressed during the day?	NeverAre you stressed during the day? Never	SometimesAre you stressed during the day? Sometimes	OftenAre you stressed during the day? Often	Very OftenAre you stressed during the day? Very Often
Do you experience cold hands or feet?	NeverDo you experience cold hands or feet? Never	SometimesDo you experience cold hands or feet? Sometimes	OftenDo you experience cold hands or feet? Often	Very OftenDo you experience cold hands or feet? Very Often
Do you notice yourself yawning regularly during the day?	NeverDo you notice yourself yawning regularly during the day? Never	SometimesDo you notice yourself yawning regularly during the day? Sometimes	OftenDo you notice yourself yawning regularly during the day? Often	Very OftenDo you notice yourself yawning regularly during the day? Very Often
Do you breathe through your mouth during the night? (Do you wake up with a dry mouth?)	NeverDo you breathe through your mouth during the night? (Do you wake up with a dry mouth?) Never	SometimesDo you breathe through your mouth during the night? (Do you wake up with a dry mouth?) Sometimes	OftenDo you breathe through your mouth during the night? (Do you wake up with a dry mouth?) Often	Very OftenDo you breathe through your mouth during the night? (Do you wake up with a dry mouth?) Very Often

What is your BOLT score? *

(Exhale through nose. Pinch nose with fingers and count how many seconds until first definite desire to breathe.)

How many hours a week do you partake in physical exercise? *

Less than 1 hour	1-2 hours	2-3 hours	3-4 hours	4-5 hours	5-6 hours	6-7 hours	7 hours or more
Less than 1 hourItem #1 Less than 1 hour	1-2 hoursItem #1 1-2 hours	2-3 hoursItem #1 2-3 hours	3-4 hoursItem #1 3-4 hours	4-5 hoursItem #1 4-5 hours	5-6 hoursItem #1 5-6 hours	6-7 hoursItem #1 6-7 hours	7 hours or moreItem #1 7 hours or more

Please indicate the level of severity of any of the symptoms that you experience in list below:

Breathing Complaints *

	None	Mild	Moderate	Severe
Coughing	NoneCoughing None	MildCoughing Mild	ModerateCoughing Moderate	SevereCoughing Severe
Wheezing	NoneWheezing None	MildWheezing Mild	ModerateWheezing Moderate	SevereWheezing Severe
Exercise induced asthma	NoneExercise induced asthma None	MildExercise induced asthma Mild	ModerateExercise induced asthma Moderate	SevereExercise induced asthma Severe
Frequent colds	NoneFrequent colds None	MildFrequent colds Mild	ModerateFrequent colds Moderate	SevereFrequent colds Severe
Breathlessness at rest	NoneBreathlessness at rest None	MildBreathlessness at rest Mild	ModerateBreathlessness at rest Moderate	SevereBreathlessness at rest Severe
Frequent sighs	NoneFrequent sighs None	MildFrequent sighs Mild	ModerateFrequent sighs Moderate	SevereFrequent sighs Severe
Frequent yawning	NoneFrequent yawning None	MildFrequent yawning Mild	ModerateFrequent yawning Moderate	SevereFrequent yawning Severe
Sleep apnea	NoneSleep apnea None	MildSleep apnea Mild	ModerateSleep apnea Moderate	SevereSleep apnea Severe
Snoring	NoneSnoring None	MildSnoring Mild	ModerateSnoring Moderate	SevereSnoring Severe
Lower back pain	NoneLower back pain None	MildLower back pain Mild	ModerateLower back pain Moderate	SevereLower back pain Severe
Excessive sweating	NoneExcessive sweating None	MildExcessive sweating Mild	ModerateExcessive sweating Moderate	SevereExcessive sweating Severe
High perceived stress	NoneHigh perceived stress None	MildHigh perceived stress Mild	ModerateHigh perceived stress Moderate	SevereHigh perceived stress Severe
Tummy upset / IBS	NoneTummy upset / IBS None	MildTummy upset / IBS Mild	ModerateTummy upset / IBS Moderate	SevereTummy upset / IBS Severe
Achy muscles	NoneAchy muscles None	MildAchy muscles Mild	ModerateAchy muscles Moderate	SevereAchy muscles Severe
Tiredness	NoneTiredness None	MildTiredness Mild	ModerateTiredness Moderate	SevereTiredness Severe
Insomnia / broken sleep	NoneInsomnia / broken sleep None	MildInsomnia / broken sleep Mild	ModerateInsomnia / broken sleep Moderate	SevereInsomnia / broken sleep Severe
Poor concentration	NonePoor concentration None	MildPoor concentration Mild	ModeratePoor concentration Moderate	SeverePoor concentration Severe
Panic Attacks	NonePanic Attacks None	MildPanic Attacks Mild	ModeratePanic Attacks Moderate	SeverePanic Attacks Severe
Headaches	NoneHeadaches None	MildHeadaches Mild	ModerateHeadaches Moderate	SevereHeadaches Severe

Nijmegen Questionnaire - Please indicate the level of severity of any of the symptoms that you experience in list below: *

	Never (0)	Rarely (1)	Sometimes (2)	Often (3)	Very Often (4)
Chest wall pains	Never (0)Chest wall pains Never (0)	Rarely (1)Chest wall pains Rarely (1)	Sometimes (2)Chest wall pains Sometimes (2)	Often (3)Chest wall pains Often (3)	Very Often (4)Chest wall pains Very Often (4)
Feeling tense	Never (0)Feeling tense Never (0)	Rarely (1)Feeling tense Rarely (1)	Sometimes (2)Feeling tense Sometimes (2)	Often (3)Feeling tense Often (3)	Very Often (4)Feeling tense Very Often (4)
Blurred vision	Never (0)Blurred vision Never (0)	Rarely (1)Blurred vision Rarely (1)	Sometimes (2)Blurred vision Sometimes (2)	Often (3)Blurred vision Often (3)	Very Often (4)Blurred vision Very Often (4)
Dizzy spells	Never (0)Dizzy spells Never (0)	Rarely (1)Dizzy spells Rarely (1)	Sometimes (2)Dizzy spells Sometimes (2)	Often (3)Dizzy spells Often (3)	Very Often (4)Dizzy spells Very Often (4)
Confusion, losing contact with reality	Never (0)Confusion, losing contact with reality Never (0)	Rarely (1)Confusion, losing contact with reality Rarely (1)	Sometimes (2)Confusion, losing contact with reality Sometimes (2)	Often (3)Confusion, losing contact with reality Often (3)	Very Often (4)Confusion, losing contact with reality Very Often (4)
Fast or deep breathing	Never (0)Fast or deep breathing Never (0)	Rarely (1)Fast or deep breathing Rarely (1)	Sometimes (2)Fast or deep breathing Sometimes (2)	Often (3)Fast or deep breathing Often (3)	Very Often (4)Fast or deep breathing Very Often (4)
Shortness of breath	Never (0)Shortness of breath Never (0)	Rarely (1)Shortness of breath Rarely (1)	Sometimes (2)Shortness of breath Sometimes (2)	Often (3)Shortness of breath Often (3)	Very Often (4)Shortness of breath Very Often (4)
Tightness in the chest	Never (0)Tightness in the chest Never (0)	Rarely (1)Tightness in the chest Rarely (1)	Sometimes (2)Tightness in the chest Sometimes (2)	Often (3)Tightness in the chest Often (3)	Very Often (4)Tightness in the chest Very Often (4)
Bloated feelings in the stomach	Never (0)Bloated feelings in the stomach Never (0)	Rarely (1)Bloated feelings in the stomach Rarely (1)	Sometimes (2)Bloated feelings in the stomach Sometimes (2)	Often (3)Bloated feelings in the stomach Often (3)	Very Often (4)Bloated feelings in the stomach Very Often (4)
Tingling of fingers	Never (0)Tingling of fingers Never (0)	Rarely (1)Tingling of fingers Rarely (1)	Sometimes (2)Tingling of fingers Sometimes (2)	Often (3)Tingling of fingers Often (3)	Very Often (4)Tingling of fingers Very Often (4)
Unable to breathe deeply	Never (0)Unable to breathe deeply Never (0)	Rarely (1)Unable to breathe deeply Rarely (1)	Sometimes (2)Unable to breathe deeply Sometimes (2)	Often (3)Unable to breathe deeply Often (3)	Very Often (4)Unable to breathe deeply Very Often (4)
Stiffness in fingers or arms	Never (0)Stiffness in fingers or arms Never (0)	Rarely (1)Stiffness in fingers or arms Rarely (1)	Sometimes (2)Stiffness in fingers or arms Sometimes (2)	Often (3)Stiffness in fingers or arms Often (3)	Very Often (4)Stiffness in fingers or arms Very Often (4)
Stiffness around the mouth	Never (0)Stiffness around the mouth Never (0)	Rarely (1)Stiffness around the mouth Rarely (1)	Sometimes (2)Stiffness around the mouth Sometimes (2)	Often (3)Stiffness around the mouth Often (3)	Very Often (4)Stiffness around the mouth Very Often (4)
Cold hands or feet	Never (0)Cold hands or feet Never (0)	Rarely (1)Cold hands or feet Rarely (1)	Sometimes (2)Cold hands or feet Sometimes (2)	Often (3)Cold hands or feet Often (3)	Very Often (4)Cold hands or feet Very Often (4)
Thumping of heart	Never (0)Thumping of heart Never (0)	Rarely (1)Thumping of heart Rarely (1)	Sometimes (2)Thumping of heart Sometimes (2)	Often (3)Thumping of heart Often (3)	Very Often (4)Thumping of heart Very Often (4)
Anxiety	Never (0)Anxiety Never (0)	Rarely (1)Anxiety Rarely (1)	Sometimes (2)Anxiety Sometimes (2)	Often (3)Anxiety Often (3)	Very Often (4)Anxiety Very Often (4)

How did you hear about this course? *

Social media
Friend
OxygenAdvantage.com
Internet search
Radio
Health care provider
Other

If 'Other', please indicate *

Nutrition

State of your Diet: In general, how would you describe your current selection of food? *

Provide a basic snapshot of what your average day of food and timing of eating looks like. Breakfast, lunch, dinner, snacks, beverages, treats, and the time of day you typically consume them.

Protein: What are your preferred protein sources? How often are they consumed? *

Whole grains: Do you eat grains? Whole or otherwise? How often do you consume them? *

Refined Carbohydrates: What types of refined carbohydrates do you consume? Include them all, baked goods and pastas, candies, crackers, cookies and how often do you eat them? *

What are your favourite foods? *

Do you try and avoid any foods in particular? *

What foods do you crave? How often do you fulfill those cravings? *

What feelings, behaviours or symptoms do you experience if you miss a meal? Elaborate? *

Are you currently consuming any nutritional supplements? Please list them here. *

Beverages: How many glasses or servings of the following do you have in a day, week or month? Please provide both the servings and frequency.

Beverage *

Serving

Frequenecy

Beverage - Coffee *

Serving - Coffee *

Frequency - Coffee *

How do you take your coffee?

Beverage - Tea *

Serving - Tea *

Frequency - Tea *

How do you take your tea?

Beverage - Fruit/vegetable juice *

Serving - Fruit/vegatable juice *

Frequency - Fruit/vegetable juice *

Beverage - Kombucha *

Serving - Kombucha *

Frequency - Kombucha *

Please provide further details around consumption of juices; types, when and why?

Beverage - Milk *

Serving - Milk *

Frequency - Milk *

Beverage - Milk (non-dairy) *

Serving - Milk (non-dairy) *

Frequency - Milk (non-dairy) *

Please provide details regarding your dairy and non-dairy milk usage? Types, when and why?

Beverage - Smoothies or shakes *

Serving - Smoothies or shakes *

Frequency - Smoothies or shakes *

Please provide details to smoothies and/or shakes; ingredients, when and why you consume either.

Beverage - Soda *

Serving - Soda *

Frequency - Soda *

Beverage - Diet soda *

Serving - Diet soda *

Frequency - Diet soda *

Beverage - Alcoholic beverages *

Serving - Alcoholic beverages *

Frequency - Alcoholic beverages *

Please provide as much details as possible. What type of drinks, when and why?

Energy and Mood

Describe your energy levels throughout an average day. Do you have highs and lows? When? *

On a scale of 1-10, how would you rate you stress level? *

1	2	3	4	5	6	7	8	9	10
11	22	33	44	55	66	77	88	99	1010

Describe your key sources of stress. *

How do you react to stress? Do you depend on any tools or mechanisms to cope? *

Sleep

Sleep quality: *

I fall asleep easily
I fall asleep quickly
I stay asleep throughout the night
I wake feeling rested and recovered
I snore
I have sleep apnea
I have trouble falling asleep
My mind doesn't rest and wanders keeping me awake
I wake up at night but can usually fall back asleep
I wake up at night but then cannot return back to sleep
I struggle to get out of bed and absolutely despise my alarm clock
I feel unrested when I wake up
I generally need more and better quality of sleep

Please check all that apply

Sleep quantity. How many hours of sleep do you get most nights?

Hours: 1

What time do you typically go to bed? *

What time do you typically wake up? *

What else do I need to know about your sleep habits, patterns, quantity, and quality? *

Movement and Fitness

Non-Exercise Movement would consist of movement of activities like walking throughout your day, general moving around, chores, manual tasks, even fidgeting, etc. Please describe your typical day’s non-exercise movement. *

Exercise is described as intentional exertion to move yourself; workout, strength training, yoga or aerobic classes, cardio, extended walks or hikes…, etc. What forms of exercise do you do? Describe the types or movements and activities, frequency, duration, intensity, etc. *

Are you a competitive athlete? *

If 'Yes', please elaborate:

What are your fitness goals?

General wellbeing
Increased muscle mass
Fat loss
Just want to look better
Improved physical performance
Improved bone density
Improved cardiorespiratory health
Prevent muscle loss
Stress management
Improved mood
Other

Please check all that apply

If 'Other', please describe:

Describe you performance goals: *

Do you have any physical limitations concerning your capability to participate in a fitness program? *

Bowel Health

How often do you have a bowel movement? *

Do you ever have difficult or unusual bowel movements? *

If 'Yes', please describe:

Work and Life

What is your focus for work? *

More often than not, do you enjoy your job? *

How many hours a day to you work?

Work Hours: 8

What is your typical work schedule? *

Regular (Mon-Fri 9AM-5AM (approx.)
Rotating or alternating
Shift work

If you selected 'Rotating' or 'Alternating' please elaborate with some specifics: *

What is life at home like? Married or single? Children? Dependents, maybe elder parents? Please share as much as you are comfortable sharing. *

Medical History

Current health conditions. Have you been diagnosed with any disease, and/or are you on any prescribed medications? *

Have you ever been hospitalized? Had major surgery? Please elaborate *

Do you have allergies or sensitivities? *

If 'Yes', please elaborate: *

Do you smoke tobacco? *

Do you smoke cannabis? *

Do you use any recreational drugs? *

If 'Yes', please elaborate and explain how often, and why? *

Please describe any pertinent family medical history.

Females

Are or could you be pregnant? *

Are you premenopausal, perimenopausal, menopausal or experiencing menopausal symptoms? *

If 'Yes', please describe: *

Conclusion

Do you have any notes, comments or questions? Please feel free to share anything. *

Acknowledgement

I understand the services provided are at all times restricted to consultation on the subject of health matters intended for general wellbeing and are not meant for the purpose of medical diagnosis, treatment or prescribing medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine, This statement is being voluntarily acknowledged.

I acknowledge *

I acknowledge

Client Signature *