MEN’S HEALTH HISTORY

MEN'S HEALTH HISTORY

All of your information will remain confidential between you and the Health Coach.
PERSONAL INFORMATION
Name
FIrst Name Last Name
Email
How often do you check email?
Phone:
Home
Works
Mobile
Age
Height
Birthdate
MM slash DD slash YYYY
Place of Birth
Current weight
Weight six months ago
One year ago
Would you like your weight to be different?
If so, what?
SOCIAL INFORMATION
Relationship status
Where do you currently live?
Children
Pets
Occupation
Hours of work per week
HEALTH INFORMATION
Please list your main health concerns
Other concerns and/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?
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
What is your food like these days?
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?
The most important thing I should do to improve my health is
ADDITIONAL COMMENTS
Anything else you would like to share

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