Men's Health History Form

Men's Confidential Health History Form

* Indicates required field

First name *

Last name *

Email *

Preferred Phone Number *

Age *

Height *

Date of Birth (xx/xx/xxxx) *

Place of Birth *

Current Weight *

Weight 6 months ago *

Weight 1 year ago *

Goal Weight *

Relationship status *

Occupation *

Children? (Y/N) *

Hours of work per week (on average) *

Please list your main health concerns and goals. *

At what point in your life did you feel best? *

Any serious illnesses, hospitalizations, or injuries? *

How is the health of your mother? *

What is your ancestry? *

How is the health of your father? *

What is your blood type? *

Do you sleep well? (Y/N) *

How many hours per night, on average? *

Do you wake up at night? If so, why? *

Any pain, stiffness, or swelling? *

Constipation/Diarrhea/Gas? Please explain. *

Allergies or sensitivities? Please explain. *

Are you involved with any other types of health therapy? If so, please list. *

What role does exercise play in your life? *

What foods did you eat often as a child?

Breakfast *

Snacks *

Lunch *

Liquids *

Dinner *

What's your diet like now?

Breakfast *

Snacks *

Lunch *

Liquids *

Dinner *

Do you think your family and friends will be supportive of your desire to make food and lifestyle changes? *

About what percentage of your food is home cooked? *

Do you cook? *

Where do you get the rest of your food from? *

Do you crave sugar, coffee, cigarettes, or have any addictions? *

I think the most important thing I should do to improve my health is: *

Anything else you want to share? *

Submit

Men's Confidential Health History Form

LIFE SHOULD FEEL GOOD

Hours

Telephone

Email