Men's Confidential Health History

contact

Name Address City State Zip

Telephones Work Home Mobile Email How often do you check email?   Constantly Hourly Daily Weekly Monthly Almost Never

personal & goals

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?

If so, what?

Relationship Status
  Single Married Domestic Partnership Divorced Widowed
Children

Pets

Occupation

Hours of Work per Week

What are your main health concerns?

Other concerns and/or goals?

medical history

At what point in your life did you feel best?

Any serious illnesses/hospitalizations/injuries?

How is the health of your father?

How is the health of your mother?

What is your ancestry?

What blood type are you?

Do you sleep well?

How many hours?

Do you wake up at night?

Why?

Any pain, stiffness or swelling?

Constipation/Diarrhea/Gas? Please explain:

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?

food

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/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?

Where do you get the rest from?

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

finish up

What role, if any, does spirituality play in your life?

What are two goals you have for the next year?

Is there anything else you would like to share?

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