Men’s Health Form

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

Personal Information

Your First Name (required)

Your Last Name (required)

Cell Phone (required)

Your Email (required)

How often do you check e-mail:

Age

Height

Birthdate

Place of Birth

Current weight

Weight 6 months ago

Weight 1 year ago

Would you like your weight to be different?

If so, what would you like your weight to be?

Social Information

Relationship Status

Where do you currently live?

Children

Pets

Occupation

Hours of work per week

Personal 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?

If so list 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?

Food Information
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

Additional Comments

Anything else you would like to share?