Men’s Health History Form

Personal Information

First Name*

Age

Last Name*

Height

Email*

Birthdate

How often do you check email

Place of Birth

Home Phone

Current Weight

Work Phone

Weight six months ago

Mobile Phone

One year ago

Would you like your weight to be different?

If so, what?

Social Information

Relationship status

Where do you currently live?

Children

Pets

Occupation

Hours of work per week

Health Information

Please list your main health concerns

What blood type are you?

Other concerns and/or goals?

How is your sleep?

At what point in your life did you feel best?

How many hours?

Any serious illnesses/hospitalizations/injuries?

Do you wake up at night?

How is/was the health of your mother?

Why?

How is/was the health of your father?

Any pain, stiffness or swelling?

What is your ancestry?

Constipation/Diarrhea/Gas?

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?

What is your food like these days?

Breakfast:

Breakfast:

Lunch:

Lunch:

Dinner:

Dinner:

Snacks:

Snacks:

Liquids:

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:

Additional Comments

Anything else you would like to share?