Men\'s Health History Form

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Men's Health History Form


		Personal Information
	Name:
	Address:
	Email:
	How often do you check email?
	Home Phone:
	Work Phone:
	Cell 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?	Yes No
	If so, what?

		Social Information
	Relationship status:
	Do you have children?
	Do you have pets?
	Occupation:
	Hours of work per week:

		Health Information
	Please list your main health concerns:
	Other concerns or goals?
	At what point in your life did you feel best?
	Any serious illness, hospitalizations or injuries?
	How is the health of your mother?
	How is the health of your father?
	What is your ancestry?
	What blood type are you?
	Do you sleep well?
	How many hours?
	Do you wake up at night?	Yes No
	If so, why?
	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:
	Are there any healers, helpers, pets 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:
		What’s your food like these days?
	Breakfast:
	Lunch:
	Dinner:
	Snacks:
	Liquids:
	Will family and friends be supportive of your desire to make food and lifestyle changes?	Yes No
	Do you cook?	Yes No
	What percentage of your food is home cooked?
	What percentage is not?
	Where do you get the rest from?
	Do you crave sugar, coffee, cigarettes, or have any major addictions? Please explain:
	The most important thing I should change about my diet to improve my health is:

		Additional Comments
	Anything else you would like to share?
	Comments:

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