Men’s Health History Form All of your information will remain confidential between you and me. Fields marked with an * are required HTML Personal Information First Name * Last Name * Email * How often do you check e-mail: Home Phone Work Phone Mobile Phone Age Height Birthdate Place of Birth Current weight Weight six months ago One year ago Would you like your weight to be different? If so, what? HTML Social Information Relationship Status Where do you currently live? Children Pets Occupation Hours of work per week HTML 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? What blood type are you? How is your sleep? How many hours? Do you wake up at night? Why? Any pain, stiffness or swelling? Constipation, diarrhea, or gas? Allergies or sensitivities? Please explain HTML 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? HTML Food Information HTML What foods did you eat often as a child? Breakfast Lunch Dinner 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? 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 HTML What is your food like these days? Breakfast Lunch Dinner Snacks Liquids HTML Additional Comments Anything else you would like to share? Print your name Confirm your permission * If you are a human seeing this field, please leave it empty.
