Men’s Health History

    Please write or print clearly. All of your information will remain confidential between you and the Health Coach.

    PERSONAL INFORMATION

    First Name:

    Last Name:

    Email:

    How often do you check email?:

    Phone: Home:

    Mobile:

    Age:

    Height:

    Birthdate:

    Place of Birth:

    Current weight:

    Weight six months ago:

    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:

    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?

    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

    Breakfast

    Lunch

    Dinner

    Snacks

    Liquid

    Breakfast

    Lunch

    Dinner

    Snacks

    Liquid

    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 INFORMATION

    Anything else you would like to share?