Men’s Health History
How often do you check email?
Home Phone Number
Work Phone Number
Mobile Phone Number
Place of Birth
Weight six months ago
One Year ago
Would you like your weight to be different?
If so, what?
Where do you currently live?
Hours of work per week
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?
How is your sleep?
How many hours?
Do you wake up at night?
How many bowel movements do you have per day?
Any pain, stiffness, or swelling?
Allergies or sensitivities? Explain please
Do you take any supplements or medications? List please:
Any healers, helpers, or therapies with which you are involved? List please:
What role do sports and exercise play in your life?
What foods did you eat often as a child?
What is your food like these days?
What is food to you?
Do your food choices support your happiness?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
What percentage of your food is made at home?
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
On a scale of 1-10 how serious are you about changing your health & your life?
Anything else you would like to share?
Should be Empty: