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Men's Health History Form
Men's Health History Form
All information will be kept confidential between you and the Health Coach. All of your information will remain confidential between you and the Health Coach.
Personal Information
Name
*
First
Last
Email
*
Home phone:
*
Work phone:
Mobile Phone:
Age:
*
Birthdate:
*
Place of birth:
*
Height:
*
Current Weight:
*
Weight Six Months Ago:
*
Weight One Year Ago:
*
Would you like your weight to be different?:
*
If so, what?:
*
Social Information
What is your current relationship status?:
*
Where do you currently live?:
*
Do you have children?:
*
Do you have any pets?:
*
What is your occupation?:
*
How many hours a week do you work?:
*
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 is your blood type?:
*
How is your sleep?:
*
How many hours a night?:
*
Do you wake up at night?:
*
Why are you waking up?:
*
Any Pain, Stiffness, or Swelling?:
*
Constipation, Diarrhea, or 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?:
*
What is your food like these days?:
*
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 Comments
Anything else you would like to share?:
*
Email
Submit
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