Men’s Health History Form

Personal Information
Name*
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 Information
Relationship status:
Where do you currently live?:
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/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 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?:
Food Information
What 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 Comments
Anything else you would like to share?:
Captcha

Personal Information

Social Information

Health Information

Medical Information

Food Information

What foods did you eat often as a child?

What is your food like these days?

Additional Comments

My FREE Gift to you!

You have Successfully Subscribed!