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Men's Health History
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First Name:
Your answer
Last Name:
Your answer
Email:
Your answer
How often do you check email?
Always
Often
Sometimes
Rarely
Never
Clear selection
Phone Number:
Your answer
Work:
Your answer
Age:
Your answer
Height:
Your answer
Birthdate:
MM
/
DD
/
YYYY
Place of Birth:
Your answer
Current Weight:
Your answer
Weight six months ago:
Your answer
Weight one year ago:
Your answer
Would you like your weight to be different?
Yes
No
Clear selection
If so, what?
Your answer
Relationship status:
Your answer
Where do you currently live?
Your answer
Children:
Your answer
Pets:
Your answer
Occupation:
Your answer
Hours of work per week:
Your answer
Please list your main health concerns:
Your answer
Other concerns and/or goals?
Your answer
At what point in your life did you feel best?
Your answer
Any serious illnesses/hospitalizations/injuries?
Your answer
How is/was the health of your mother?
Your answer
How is/was the health of your father?
Your answer
What is your ancestry?
Your answer
What blood type are you?
Your answer
How is your sleep?
Your answer
How many hours?
Your answer
Do you wake up at night?
Yes
No
Clear selection
Why?
Your answer
Any pain, stiffness, or swelling?
Yes
No
Clear selection
Any pain, stiffness, or swelling?
Yes
No
Clear selection
Allergies or sensitivities? Please explain:
Your answer
Do you take any supplements or medications? Please list:
Your answer
Any healers, helpers, or therapies with which you are involved? Please list:
Your answer
What role do sports and exercise play in your life?
Your answer
What foods did you eat often as a child? (BREAKFAST)
Your answer
What foods did you eat often as a child? (LUNCH)
Your answer
What foods did you eat often as a child? (DINNER)
Your answer
What foods did you eat often as a child? (SNACKS)
Your answer
What foods did you eat often as a child? (LIQUIDS)
Your answer
What is your food like these days? (BREAKFAST)
Your answer
What is your food like these days? (LUNCH)
Your answer
What is your food like these days? (DINNER)
Your answer
What is your food like these days? (SNACKS)
Your answer
What is your food like these days? (LIQUIDS)
Your answer
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Yes
No
Clear selection
Do you cook?
Yes
No
Clear selection
What percentage of your food is home-cooked?
Your answer
Where do you get the rest from?
Your answer
Do you crave sugar, coffee, cigarettes, or have any major addictions?
Yes
No
Clear selection
The most important thing I should do to improve my health is:
Your answer
Anything else you would like to share?
Your answer
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