Men's Confidential Health History.

 

Contact Information

Name: First Last

Street Address:

City: State:

Postal Code:

Email Address:

Contact Phone: ( ) -

How often do you check Email? Do you Prefer:

 

 

Basic Information

Age: Date of birth: How old do you feel?

Height: Place of birth:

Sex:

Current Weight: Weight six months ago: One year ago:

Would you like your weight to be different?

If so what?

What is your ancestry?

What blood type are you?

How is/was the health of your mother?

How is/was the health of your father?

 

 

 

Career

Current Place of employment:

Position held: Hours work:

Secondary Place of employment:

Position held: Hours work:

Are you currently in school? If so for what?

On a scale of 1-10 (10 being most severe) How stressful is your career?

On a scale of 1-10 (10 being most positive) How satisfying is your career?

On a scale of 1-10 (10 being most positive) How organized are you?

Would you like to change your career?

If yes then to what?

 

Relationships and spiritual

Relationship status: Children:

Pets:

Do you have a network of friends?

Do you practice religion? If so what?

Will family and friends be supportive of your desire to make lifestyle changes?

On a scale of 1-10 (10 being most positive) How satisfying are your relationships??

On a scale of 1-10 (10 being most positive) How in control do you feel about your life now?

 

 

Nutrition and Diet

Do you cook?

What percentage of your meals are home cooked?

where does the rest come from?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

The most important thing I should change about my diet to improve my health is:

How often/ quantity do you consume alcohol?

On a scale of 1-10 (10 being most positive) How satisfying is your food???

Childhood

What foods did you eat as a child for breakfast?

What foods did you eat as a child for lunch?

What foods did you eat as a child for dinner?

What foods did you eat as a child for snacks?

 

 

Currently

What foods do you eat now for breakfast?

What foods do you eat now for lunch?

What foods do you eat now for dinner?

What foods do you eat now for snacks?

 

 

 

Health Information

Do you sleep well? How many hours?

Do you wake up at night?

If so why?

Any pain, stiffness or swelling?

Constipation/Diarrhea/Gas? Please explain:

Allergies or sensitivities? Please explain:

Do you take any medications? Please list:

Do you take any supplements? Please list:

Ay healers, helpers, or therapies which you are involved? Please list:

What role does sports and exercise play in your life?

Please list and describe your health concerns:

Other concerns or goals:

At what point in your life did you feel best and why?

Any serious Illnesses/ hospitalizations, injuries?

Anything else yo would like to share?

 

 

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