Men’s Health History

All of your information will remain confidential between you and your Health Coach.

Personal Information

Your Name (required)

Your Email (required)

How often do you check email

Mobile Phone

Age

Height

Date of Birth

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

Where Do You Currently Live?

Do You Have Children?
 Yes No

Do You Have Pets?
 Yes No

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 Illnesses / Hospitalizations / Injuries?

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?
 Yes No

Why?

Any Pain, Stiffness Or Swelling?

Any Constipation, Diarrhea, Gas?

Any Allergies Or Sensitivities?


Medical Information

Do You Take Any Supplements Or Medications?

Any Healers, Helpers Or Therapies With Which You're Involved?

What Role Do Sports And Exercise Play In Your Life?


Food Information

What Foods Did You Eat Often As A Child For Breakfast?

What Foods Did You Eat Often As A Child For Lunch?

What Foods Did You Eat Often As A Child For Dinner?

What Foods Did You Eat Often As A Child For Snacks?

What Liquids Did You Drink Often As A Child?

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:

What Foods Do You Eat Today For Breakfast?

What Foods Do You Eat Today For Lunch?

What Foods Do You Eat Today For Dinner?

What Foods Do You Eat Today For Snacks?

What Liquids Do You Drink Today?


Additional Comments

Anything Else You Would Like To Share?