Men’s Health History

Please fill out as fully as possible.

Name
Address
AddressAddress Line 2CityState / Province / RegionPostal / Zip CodeCountry
Email *
Text
How often do you check e-mail?
Home Phone
Work Phone
Mobile Phone
Age
Height
Birthdate
Place of Birth
Current Weight
Weight six months ago
Weight one year ago
Would you like for your weight to be different?
If so, how would you like it to be different?

Relationship Status
Any children?
Pets?
Occupation
How many hours a week do you work?

Health Information

Please list your main health concerns
Other concerns and/or goals?
At what point in your life did you feel best?
Any serious illness/hospitalizations/injuries?
How is/was the health of your mother?
How is/was the health of your father?
What is your ancestry?
What blood type are you?
Do you sleep well?
How many hours a night do you sleep?
Do you wake up at night?
If so, why?
Any pain, stiffness or swelling?
Do you have diarrhea, gas, bloating or constipation?
Allergies or sensitivities? (Please explain)

Medical Information

Do you take any supplements or medications? If so, please list.
Any healers, helpers, pets or therapies with which you are involved? If so, please list.
What role do sports and exercise play in your life?

What foods did you eat regularly as a child?

Breakfast
Lunch
Dinner
Snacks
Beverages

What is your food like these days?

Breakfast
Lunch
Dinner
Snacks
Beverages

Other Information

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?
What percentage is not?
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I should change about my diet to improve my health is:
Anything else you would like to share?

Verification

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