Health History

Men’s Health History

Please write or print clearly. All of your information will remain confidential between you and the Health Coach.

PERSONAL INFORMATION

First Name

Last Name

How often do you check email?

Phone Home:

Mobile

Work:

Age:

Height:

Birthdate:

Place of Birth:

Current Weight:

Weight six (6) months ago:

One Year ago:

Would you like your weight to be different?

If so, what?

SOCIAL INFORMATION

Relationship Status:

Where do you currrently 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?

Men’s Health History

PERSONAL INFORMATION

SOCIAL INFORMATION

HEALTH INFORMATION

MEDICAL INFORMATION

FOOD INFORMATION

ADDITIONAL INFORMATION

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