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Men's Health History Form
Personal Information
Name:
Age:
Address:
Height:
E-mail:
Birthdate:
How often do you check mail:
Place of birth:
Home Phone:
Current weight:
Work Phone:
Weight six months ago:
Cell Phone:
One year ago:
Would you like your weight to be different:
If so, what?:
Social Information
Relationship status?:
Children?:
Pets?:
Occupation?:
Hours of work per week:
Health Information
Please list your main health concerns:
What blood type are you?:
Other concerns and/or goals?:
Do you sleep well?:
At what point in your life did you feel best:
Do you wake up at night?:
Any serious illness/hospitalizations/injuries:
Why?:
How is/was the health of your mother?:
Any pain, stiffness or swelling?:
How is/was the health of your father?:
Constipation/Diarrhea/Gas?:
What is your ancestry?:
Allergies or sensitivities? Please explain:
Medical Information
Do you take any supplements or medications:
Any healers, helpers, pets or therapies with which you are involved?:
Please List:
Please List:
What role do sports and exercise play in your life?:
Food Information:
What foods did you eat often as a child?
What’s your food like these days?
Breakfast
Breakfast
Lunch
Lunch
Dinner
Dinner
Snacks
Snacks
Liquids
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?:
What percentage is not?:
Where do you get the rest?:
Do you crave sugar, coffee, cigarettes, or have any major addictions?:
The most important thing I should change about my diet to improve my health is:
Aditional Comments
Anything else you would like to share?:
