Men’s Health History

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

    Personal Information


    First Name (required)

    Last Name (required)

    Your Email (required)

    How often do you check email?

    Home Phone:

    Work Phone:

    Mobile Phone:

    Age:

    Height:

    Birth Date:

    Place of Birth

    Current weight

    Weight 6 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 illness/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?

    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 food do 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?

    thời trang trẻ emWordpress Themes Total Freetư vấn xây nhàthời trang trẻ emshop giày nữdownload wordpress pluginsmẫu biệt thự đẹpepichouseáo sơ mi nữHouse Design Blog - Interior Design and Architecture Inspiration