Men’s Confidential Health History

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Printable Form

Name *

Name

First Name

Last Name

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address *

How often do you check email? *

Phone Number *

Work, cell, home

Age/Height *

Date and Place of Birth *

Weight *

Current, 6 months ago, 1 year ago

Would you like your weight to be different? If yes, how so? *

Relationship Status *

Do you have any children? Please list: *

Do you have any pets? Please list: *

What is your occupation, and how many hours do you work/week? *

Please list your main health concerns and goals. *

At what point in your life did you feel best? *

Any serious illnesses/hospitalizations/injuries? *

How is the health of your parents? *

What is your ancestry? *

What is your blood type? *

How many hours do you sleep at night? *

Do you wake up at night? If so, why? *

Any pain, stiffness or swelling? *

How is your digestion? Constipation/Diarrhea/Gas? Please explain: *

Do you have any allergies or sensitivities? Please explain: *

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? *

What foods did you eat often as a child? *

Breakfast, Lunch, Dinner, Snacks, Liquids

What foods make up your current diet? *

Breakfast, Lunch, Dinner, Snacks, Liquids

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? *

Do you crave sugar, coffee, cigarettes, or have any major addictions? *

What percentage of your food is home-cooked? Do you cook? *

What is the source of your food that is not home-cooked? *

The most important thing I should change about my diet to improve my health is: *

Anything else you want to share? *

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