Email Address

How often do you check your email?

Age:

Height:

Place of birth:

Home phone:

Work phone:

Mobile phone:

Current weight:

Weight six months ago:

One year ago:

Would you like your weight to be different?

If so, what?

Relationship status:

Where do you currenty live?

Children?

Pets?

Occupation:

Hour of work per week:

Please list your main health concerns:

Other concerns/goals?

At what point in your life did you feel your 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/gas/diarrhea?

Allergies or sensitivities? Please explain:

Do you take any supplements or mediaction? Please list:

Any healers, helpers or therapists with which you are involved? Please list:

What role do sports play in your life?

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:

Anything else you would like to share?

Men's Health History