Men's Health History Form
How often do you check e-mail:
Weight 6 Months Ago
Weight 1 Year Ago
Would you like your weight to be different?:
If so what?:
Where do you currently live?
How many hours do you work a week?
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?:
Any pain, stiffness or swelling?:
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?:
What foods did you eat often as a child? Breakfast:
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:
What is your food like these days? Breakfast:
Anything else you would like to share?:
I consent to having this website store my submitted information so they can respond to my inquiry.
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