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