Men’s Health History

All of your information will remain confidential between you and the Health Coach.

Personal Information
First Name*
Last Name*
Email*
How often do you check e-mail
Home Phone
Work Phone
Mobile Phone
Age
Height
Birthdate
Place of Birth
Current weight
Weight six months ago
Weight one year ago
Would you like your weight to be different?
If so, what would you like your weight to be?
Social Information
Relationship 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?
Any pain, stiffness or swelling?
Constipation/Diarrhea/Gas?
What is your ancestry?
What blood type are you?
Allergies or sensitivities? Please explain
Any serious illnesses/hospitalizations/injuries?
How is/was the health of your mother?
How is/was the health of your father?
At what point in your life did you feel best?
How is your sleep?
How many hours of sleep do you get?
Do you wake up at night? If so, why?
Medical Information
Do you take any supplements or medications? Please list
What role do sports and exercise play in your life?
Any healers, helpers or therapies with which you are involved? Please list
Food Information
What foods did you eat often as a child?
What is your food like these days?
Breakfast foods as a child:
Breakfast foods these days:
Lunch foods as a child:
Lunch foods these days:
Dinner foods as a child:
Dinner foods these days:
Snack foods these days:
Snack foods these days:
Liquids as a child:
Liquids these days:
Do you cook?
What percentage of your food is home-cooked?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
Where do you get your rest from?
The most important thing I should do to improve my health is
Additional Comments
Anything else you would like to share?

Personal Information

Social Information

Health Information

Medical Information

Food Information

Additional Comments