About
Meet Lauren
What Is Health Coaching?
Available Services
Yoga
Speaking/Group Presentations
Corporate Wellness
Health Coaching
Recipes
Free Resources
Podcasts
Guided Meditations
Webinars
Forms
Women’s Health History
Men’s Health History
Revisit Form
Contact
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
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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?
Δ
login
- site by
ok7