Men’s Health History – Sharina McMahon

Men's Health History

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

Name

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?