Men's Health History Form

Personal Information

Name
Address
Email
How often do you check mail?
Work phone
Cell phone

Age
Height
Birthday
Place of birth
Current weight
Weight six month's ago
One year ago
Would you like your weight to be different?
If so, what?

Social Information

Relationship status
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 the health of your mother?
How is the health of your father?
What is your ancestry?

What blood type are you?
Do you sleep well?
How many hours?
Do you wake up at night?
Why?
Any pain, stiffness or swelling?
Constipation / Diarrhea / Gas?
Allergies or sensitivites? Please explain

Medical Information

Do you take any supplements or medications?
Please list

Any healers, helpers, pets or therapies with which you are involved?
Please list
What role do sports and exercise play in your life?

Food Information

What foods did you eat often as a child?

Breakfast
Lunch
Dinners
Snacks
Liquids

What's your food like these days?

Breakfast
Lunch
Dinners
Snacks
Liquids

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?
What percentage is not?
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I should change about my diet to improve my health is

Additional comments

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