Men’s Health History Form Personal InformationName* First Last Email* How often do you check emails? Home Phone*Work Phone:Mobile:Age: Height: Birthdate: Month Day Year Place of Birth? Current Weight: Weight six months ago: Weight one year ago: Would you like your weight to be different?: If so, what?: Social InformationRelationship status: Where do you currently live?: Children: Pets: Occupation: Hours of work per week: Health InformationPlease 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/Gas?:Allergies or sensitivities? Please explain:Medical InformationDo 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?:Food InformationWhat foods did you eat often as a child?Breakfast:Lunch:Dinner:Snacks:What is your food like these days?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:Additional CommentsAnything else you would like to share?:Captcha Δ