MENS HEALTH HISTORY

MENS HEALTH HISTORY
Personal Information
Name:

First NameLast Name
Email:
example@example.com
How often do you check email?
Phone Number Mobile:

Area CodePhone Number
Phone Number Work:

Area CodePhone Number
Phone Number Home:

Area CodePhone Number
Date of Birth:

MonthDayYear
Date
Age:
Place of Birth:
Height:
Weight:
Weight 6 months ago:
Weight 1 year ago:
Would you like your weight to be different?
If the answer to the above question was YES, what would you like your weight to be?
Social Information
Relationship Status:
Do you have children? Pets?
Occupation:
How many hours per week do you work?
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?
Blood Type:
How is your sleep?
How many hours do you sleep at night on average?
Do you wake up at night?
If you do 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?
Medical Information

What foods did you eat as a kid?

What foods do you eat now?

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 Comments
Anything else you would like to share?
Should be Empty:

Personal Information