Men’s Health History Form

If you have already scheduled a consultation or are an existing client, please fill out the appropriate form below.

Personal Information

Name (required) Email (required)
Home phone Work phone
Mobile phone
Age Height
Birth date Place of birth
Current weight Weight six months ago
Weight one year ago Would you like your weight to be different?  Yes No
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 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 is your blood type?
How is your sleep? How many hours?
Do you wake up at night? If so, why?
Any pain, stiffness or swelling? Constipation/Diarrhea/Gas?
Allergies or sensitivities? Please explain: Are you periods regular?

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 often eat as a child? What is your food like these days?
Breakfast: Breakfast:
Lunch: Lunch:
Dinner: Dinner:
Snacks: Snacks:
Liquids: Liquids:

Will friends and family be supportive of your desire to make food and/or lifestyle changes?
Do you cook? If so, what percentage of your food is home-cooked?
Where do you get the rest of your food 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