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Men's Confidential Health History Form
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Indicates required field
First name
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Last name
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Email
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Preferred Phone Number
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Age
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Height
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Date of Birth (xx/xx/xxxx)
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Place of Birth
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Current Weight
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Weight 6 months ago
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Weight 1 year ago
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Goal Weight
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Relationship status
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Occupation
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Children? (Y/N)
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Hours of work per week (on average)
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Please list your main health concerns and goals.
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At what point in your life did you feel best?
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Any serious illnesses, hospitalizations, or injuries?
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How is the health of your mother?
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What is your ancestry?
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How is the health of your father?
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What is your blood type?
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Do you sleep well? (Y/N)
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How many hours per night, on average?
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Do you wake up at night? If so, why?
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Any pain, stiffness, or swelling?
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Constipation/Diarrhea/Gas? Please explain.
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Allergies or sensitivities? Please explain.
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Are you involved with any other types of health therapy? If so, please list.
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What role does exercise play in your life?
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What foods did you eat often as a child?
Breakfast
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Snacks
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Lunch
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Liquids
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Dinner
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What's your diet like now?
Breakfast
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Snacks
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Lunch
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Liquids
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Dinner
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Do you think your family and friends will be supportive of your desire to make food and lifestyle changes?
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About what percentage of your food is home cooked?
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Do you cook?
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Where do you get the rest of your food from?
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Do you crave sugar, coffee, cigarettes, or have any addictions?
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I think the most important thing I should do to improve my health is:
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Anything else you want to share?
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Submit
Home
My Approach
About Me
Ionic Foot Detox Bath
Ionic Foot Detox Consent Form
Bach Flower Essenses
Reishi Mushroom Tincture
Hand Sanitizer
Contact Me
Product