Men’s Health History

Personal Information

First Name: *
Last Name: *
Email: *

Home Phone:
Work Phone:
Mobile Phone:
Preferred Contact Method:

Personal Profile

Age:
Height:
Birthdate:
Place of Birth:

Current Weight:
Weight six months ago:
Weight one year ago:
Would you like your weight to be different?
If so, how?

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:

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 mother?:
How is/was the health of your father?:
What is your ancestry?:
What blood type are you?:
How is your sleep?:

How many hours?:
Do you wake up at night?:
If so, why?
Any pain, stiffness or swelling?
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?
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:

What is your food like these days?

Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:

Additional Comments

Anything else you would like to share?:

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