Men's Health History Questionnaire
Please write or print clearly. All of your information will remain confidential between you and the Health Coach.
PERSONAL INFORMATION
Today's Date
MM
/
DD
/
YYYY
First Name:
Your answer
Last Name:
Your answer
Email
Your answer
How often do you check email?
Phone
Your answer
Age
Your answer
Height
Your answer
Birthdate
Your answer
Place of Birth
Your answer
Current Weight
Your answer
Weight six months ago
Your answer
One year ago
Your answer
Would you like your weight to be different?
Your answer
If so, what?
Your answer
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