My Soulplate - Medical & Lifestyle Screening
Today's Date
-
Month
-
Day
Year
Date Picker Icon
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Part 1: Personal Details
Name
*
Address
*
City, State, Zip
*
Phone Number
*
Mobile
E-mail
*
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Part 2: Goal Setting
GOAL One
GOAL Two
GOAL Three
Why is this important to you?
Have you ever worked with a Nutrition Coach before?
Yes
No
What is your current exercise program?
What is the biggest challenge that you must overcome in order to achieve your goal?
Part 3: Medical History
Have you ever suffered from...?
Asthma
High Blood Pressure
Low Blood Pressure
Epilepsy
Arthritis
Diabetes
Frequent Colds
Dizziness/fainting
Heart Disease
Shortness of breath
High Cholesterol
Palpitations
Headaches
Migraines
NONE
Have any of your first degree relatives experienced the following conditions?
Heart Attack
High Cholesterol
High Blood Pressure
Congenital Heart Disease
Diabetes
NONE
Have you ever had surgery? If "yes", please list.
Do you suffer from back pain?
What is your ‘chief complaint’ or major injury?
Please list any medications AND/OR supplements that you are currently taking:
Part 4: Occupation & Lifestyle
Please explain your occupation.
How do you feel about your job?
How many hours do you spend in front of a computer per day?
Please Select
0-2
2-4
4-6
6-8
8-10
10+
Please Choose
Do you travel for work? How often?
How much time do you spend in a seated position per day?
Please Select
0-2
2-4
4-6
6-8
8-10
10-12
12-14
14+
Please Choose
Are you active on a daily basis?
Yes
No
How many hours sleep do you get each night?
Please Select
0-2
2-4
4-6
6-8
8-10
10+
Please Choose
Do you consider yourself to be under any stress?
Yes
No
Do you smoke?
Yes
No
Never
When would you say you were in the best shape of your life?
Please Select
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
Please Choose
What were you doing? What has changed?
Are there any leisure activities you enjoy doing?
Please Select
Football
Mountain Biking
Road Cycling
Rugby
Running
Tennis
Skiing
Snowboarding
MMA
Sailing
Aerobic Classes
Other
Please Choose
Part 5: Nutrition
Do you experience fatigue or lack of energy?
Yes
No
How would you describe your nutritional habits?
Bad
Good
Optimal
Have you ever suffered from any of the following?
Digestive Problems
Allergies
Kidney Problems
Food Intolerances
Liver Problems
NONE
Favorite Foods (Please list as many as you would like.)
Proteins:
Fruits:
Vegetables:
Drinks:
Desserts:
Other:
Please read and acknowledge the following statements.
I understand that the information collected by My Souplate will be used for the design, implementation, progression, and maintenance of an individual fitness nutrition program only. I further undestand that all such information is confidential and will not be shared with anyone without my prior written authorization, except in the case of a medical emergency or to the minimum extent necessary to achieve a safe and effective fitness nutrition program.
Yes
No
Submit
Should be Empty: