Men's Health History Form

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

How often do you check email?

Phone (Work):

Phone (Home):

Phone (Mobile):

Age:

Height:

Date of Birth:

Place of Birth:

Weight:

Weight 6 months ago:

Weight 1 year ago:

Would you like your weight to be different?

If so, what?

Relationship status:

Children:

Pets:

Occupation:

Hours of work per week:

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 father?

How is the health of your mother?

What is your ancestry?

What blood type are you?

Do you sleep well?

How many hours?

Do you wake up at night?

If so, why?

Any pain, stiffness or swelling?

Constipation/Diarrhea/Gas? Please explain:

Allergies or sensitivities? Please explain:

Do you take any supplements or medications? Please list:

Any healers, helpers or therapies with which you are involved? Please list:

What role does sports and exercise play in your life?

What foods did you eat often as a child?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

What’s 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 crave sugar, coffee, cigarettes, or have any major addictions?

What percentage of your food is home cooked?

Do you cook?

Where do you get the rest from?

The most important thing I should change about my diet to improve my health is:

Anything else you want to share?

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