health history mens

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Men’s Health History (Confidential) Please write or print clearly




! Text Today’s Date: _____________________________

Text First Name: ________________________

Text Last Name: _______________________________

Text Address: _____________________________________________________________________ Text Email Address: _________________________ Text Cell #: _________________ Preferred form of contact:

Text How often do you check email? __________

Text Work #: _________________

! Email

! Text

! Cell

! Work

Text Home #: _________________ ! Home

! Text Age: ___________

Text Height: ____________

Text Weight 6 months ago: _______

Text Weight: ___________

Text Weight a year ago: ________

Relationship Status: __________________

Ideal Weight ____________

Living in a: ! House

Children: _____________________________

! Apt/Condo/Multi-Family

Pets: __________________________________

Occupation: ______________________________________

Hours worked per week: _______

Will family/friends be supportive of your food/lifestyle changes?

! Yes

! No

! Maybe

! Date of Birth: ____________

Place of Birth: _______________________________________

What is your ancestry? _____________________________________

Blood Type: _________

How was the health of your father? ________________________________________________ _____________________________________________________________________________ How was the health of your mother? _______________________________________________ _____________________________________________________________________________

! Please list your main health concerns: ______________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Any serious illnesses/hospitalizations/injuries? (please list in detail with dates – use separate sheet if necessary) _____________________________________________________________

_____________________________________________________________________________ What role does sports/exercise play in your life? ______________________________________ _____________________________________________________________________________ Do you sleep well? ! Yes

! No

Do you wake up at night? ! Yes

! Sometimes ! No

How many hours? _____________________

! Sometimes

Why? __________________________

_____________________________________________________________________________ Describe any pain, stiffness, swelling: ______________________________________________ Describe any Constipation/Diarrhea/Gas: ___________________________________________ What medical/healers/therapy providers do you work with? _____________________________ _____________________________________________________________________________ List all medications or supplements: _______________________________________________ ____________________________________________________________________________ Known allergies or sensitivities: ___________________________________________________ Do you crave sugar, coffee, cigarettes, or have any addictions? (describe) _________________ _____________________________________________________________________________ What foods did you eat most often as a child? Breakfast: ____________________________________________________________________ _____________________________________________________________________________ Lunch: _______________________________________________________________________ _____________________________________________________________________________ Dinner: ______________________________________________________________________ _____________________________________________________________________________ Snacks: ______________________________________________________________________ _____________________________________________________________________________ Liquids: ______________________________________________________________________ _____________________________________________________________________________

! What foods do you east most often now? Breakfast: ____________________________________________________________________

_____________________________________________________________________________ Lunch: _______________________________________________________________________ _____________________________________________________________________________ Dinner: ______________________________________________________________________ _____________________________________________________________________________ Snacks: ______________________________________________________________________ _____________________________________________________________________________ Liquids: ______________________________________________________________________ _____________________________________________________________________________ What percentage of your food is home cooked? _____________ Do you cook? _____________ Where does the rest of your food come from? _______________________________________

! The most important thing I should change about my diet to improve my health is: ___________ _____________________________________________________________________________ My primary health/fitness/nutritional goals are: _______________________________________ _____________________________________________________________________________ _____________________________________________________________________________ My primary concerns about reaching those goals are: __________________________________ _____________________________________________________________________________ _____________________________________________________________________________ At what point in your life did you feel at your best/healthiest? ___________________________ _____________________________________________________________________________ Is there anything else you’d like to share? ___________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________