MEN'S HEALTH HISTORY

MEN'S HEALTH HISTORY
Please write or print clearly. Your information will remain confidential between you and your Health Coach.
Personal
First Name*
Last Name*
Age*
Height*
Date of Birth*

MonthDayYear
Date
Place of Birth*
Email*
example@example.com
How often do you check your email?*
numbers of time
Home Phone
Work Phone
Mobile Phone*
Current Weight*
Weight Six Ago*
Weight One Year Ago*
Would you like your weight to be different?*
If so, how?*
Social
Relationship Status*
Where do you live?*
Any children?*
Any pets?*
Occupation*
How many hours do you work per week?*
General Health
What are your main health concerns?*
Any other concerns and/or goals?*
At what point in your life did you feel your best?*
Any current or previous serious illnesses, hospitalizations, or injuries?*
How is/was your mother's health?*
How is/was your father's health?*
What is your ancestry?*
What is your blood type?*
C2007, 2017 Integrative Nutrition, Inc. | Reprinted with permission
MEN'S HEALTH HISTORY
How is your sleep?*
How many hours do you sleep per night?*
Do you wake up during the night? If so, why?*
Any pain, stiffness, or swelling?*
Any constipation, diarrhea, or gas?*
Any allergies or sensitivities?*
Medical
List all supplements or medications*
Are you involved with any healers, helpers, or therapies?*
What role does sports and exercise play in your life?*
Food
Will your family and 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 does your non-home-cooked food come from?*
What foods did you eat often as a child for breakfast?*
What foods did you eat often as a child for lunch?*
What foods did you eat often as a child for dinner?*
What foods did you eat often as a child for snacks?*
What drinks did you drink often as a child for liquids?*
What foods do you typically eat these days for breakfast?*
What foods do you typically eat these days for lunch?*
What foods do you typically eat these days for dinner?*
What foods do you typically eat these days for snacks?*
What drinks do you typically drink these days for liquids?*
C 2007, 2017 Integrative Nutrition, Inc. | Reprinted with permission
MEN'S HEALTH HISTORY
Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions?*
What is the most important thing you should change about your diet to improve your health?*
Additional comments
Is there anything else you would like to share?*
C 2007, 2017 Integrative Nutrition, Inc. | Reprinted with permission
Should be Empty:

MEN'S HEALTH HISTORY

Personal

Social

General Health

MEN'S HEALTH HISTORY

Medical

Food

MEN'S HEALTH HISTORY

Additional comments