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Home
About
About Me
My Approach
Work With Me
Resources
Recipes
Health Forms
Blog
Contact
MEN’S HEALTH FORM
Men's Health
First Name
Last Name
Email Address
How often do you check email?
Best Phone Number to Reach You
Birthday
Place of Birth
Current Weight
Weight Six Months Ago
Weight One Year Ago
Would you like your weight to be different? If so, how?
Social Information
Relationship Status
Where do you currently live?
Children?
Pets?
Occupation
How many hours do you work per week?
Health Information
Please list your main health concerns:
Other concerns and/or goals?
Any serious illnesses/hospitalizations/injuries?:
At what point in your life did you feel best?
How is/was the health of your mother?
How is/was the health of your father?
What is your ancestry?
What blood type are you?
How is your sleep?
How many hours?
Do you wake up at night? If so, why?
Any pain, stiffness or swelling?
Constipation/Diarrhea/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?
Breakfast
Lunch
Dinner
Snacks
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?
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
What is your food like these days?
Breakfast
Lunch
Dinner
Snacks
Liquids
The most important thing I should do to improve my health is:
Anything else to add?
Additional Comments