Men's Health History Form

Name
First Last
Email
How often do you check e-mail:
Phone
Age
Height
Birth Date
Month
Day
Year
Place of Birth
Weight One Year Ago
Would You Like Your Weight to be Different?
What Would You Like Your Weight to Be?
Social Information
Relationship Status
Where do you currently live?
Children
Pets
Occupation
Hours of Work Per Week
Health Information
Main Health Concerns
Other concerns and/or goals?:
At what point in your life did you feel best?:
Any serious illnesses/hospitalizations/injuries?:
How is/was the health of your father?:
How is/was the health of your mother?:
What is your ancestry?:
What blood type are you?:
How is your sleep?:
How many hours?:
Do you wake up at night?:
Why
Constipation/Diarrhea/Gas?:
Any pain, stiffness or swelling?:
Allergies or sensitivities? Please explain:
Medical Information
Do you take any supplements or medications? Please list:
Any healers, helpers or therapies with which you are involved? Please list:
What role do sports and exercise play in your life?:
Food Information
What foods did you eat often as a child?
Breakfast
Lunch
Dinner
Snacks
Liquids
What is your food like these days?
Breakfast
Lunch
Dinner
Snacks
Liquids
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Do you cook?
What percentage of your food is home-cooked?
Where do you get the rest from?:
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I should do to improve my health is:
Anything else you would like to share?

Social Information