Men Health History

Please write or print clearly. All of your information will remain confidential between you and the Health Coach.

Personal Information

First Name

Last Name

Home Phone

Age

Work Phone

Height

Mobile Phone

Birthday

Place of birth

Current Weight

Weight 6 months ago

Would you like your weight to be different

Weight 1 year ago

If so what

Social Information

Relstionship 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 & Liquids

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 Information

Anything else you would like to share?

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Women Health History