Men's Health History Form Personal InformationFirst Name Last Name Email How often do you check e-mail Home Phone Work Phone Mobile Phone Age Height Birthdate Place of Birth Current Weight Weight 6 Months Ago Weight 1 Year Ago Would you like your weight to be different? No YesIf so, what? Social InformationRelationship Status Children Pets Occupation Hours of work per week Where do you currently live? Health InformationPlease 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 is your blood type? How is your sleep? How many hours? Do you wake up at night? No YesIf yes, why? Any pain, stiffness or swelling? Constipation/Diarrhea/Gas? Allergies or sensitivities? Please explain Medical InformationDo 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 InformationWhat 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? No YesWhat percentage of 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? Powered by ChronoForms - ChronoEngine.com
