Health Coaching - Men's Health History

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

PERSONAL INFORMATION
Name

First Name Last Name
Best email address to reach you at?
example@example.com
How often do you check your email?
Please enter a phone number to contact you:
Please leave your social media link here as another method to reach you.
Enter your age:
Enter your birth date:

Month Day Year
Date
Place of Birth:
Please enter your height here:
Please tell me your current weight:
Please tell me what your weight was six months ago and what it was a year ago:
Would you like your weight to be different? If so, what is your goal?
SOCIAL INFORMATION
Relationship status?
Where do you currently live?
Any children?
Any pets?
Occupation:
Hours of work per week:

FOOD INFORMATION
What foods did you eat often as a child?
What is your food like these days?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Do you cook? If so what percentage of your food is home-cooked?
Where do you get the rest of your food from? How much of your food is takeout?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I should do to improve my health is:
Do you have any additional things that you would like to share to help me better assist you?
Should be Empty:

Men’s Health History