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Men's Health History
All of your information will remain confidential between you and the Health Coach.
Name
Email
Phone Number
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?
Relationship Status
Where do you currently live?
Children
Pets
Occupation
Hours of Work Per 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?
Why?
Any pain, stiffness, or swelling?
Constipation/Diarrhea/Gas?
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 for Breakfast?
What foods did you eat often as a child for Lunch?
What foods did you eat often as a child for Dinner?
What foods did you eat often as a child for Snacks?
What foods did you eat often as a child for Liquids?
What is your food like these days for Breakfast?
What is your food like these days for Lunch?
What is your food like these days for Dinner?
What is your food like these days for Snacks?
What is your food like these days for 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:
Anything else you would like to share?
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