Men’s Health History Personal Information Name: * Address: Email: * How often do you check email: Home Phone: Work Phone: Cell Phone: Age: Height: Birthdate: Place of Birth: Current Weight: Weight six months ago: One year ago: Would you like your weight to be different: If so, what?: Social Information Relationship status: Children: Pets: Occupation: Hours of work per week: Health Information Please list your main health concerns: Other concerns and/or goals?: At what point in your life did you feel best: Any serious illness/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?: Do you sleep well?: How many hours?: Do you wake up at night?: Why?: Any pain, stiffness or swelling?: Constipation/Diarrhea/Gas?: Allergies or sensitivities? Please explain: Medical Information Do you take any supplements or medications?: Please List: Any healers, helpers, pets or therapies with which you are involved?: Please list: What role do sports and exercise play in your life?: Food Information What foods did you eat often as a child? Breakfast: Lunch: Dinner: Snacks: Liquid: What's your food like these days? Breakfast: Lunch: Dinner: Snacks: Liquid: 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?: What percentage is not?: Where do you get the rest 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: Additional Comments Anything else you would like to share?: Type these characters into the box below: