Men's Health History
All of your information will remain confidential.
PERSONAL INFORMATION
First Name
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Last Name
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Email
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Phone (Home):
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Phone (Mobile):
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Phone (Work):
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Age:
Your answer
Height:
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Birthdate:
MM
/
DD
/
YYYY
Place of Birth:
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Current Weight:
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Weight six months ago:
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Weight one year ago:
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Would you like your weight to change?
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If yes, how would you like it to change?
Your answer
SOCIAL INFORMATION
Relationship Status:
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Where do you currently live?
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Children:
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Pets:
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Occupation:
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Hours of work per week:
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HEALTH INFORMATION
Please list your main health concerns:
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Are there any other concerns or goals?
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At what point did you feel your best?
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Any serious illnesses/hospitalizations/injuries?
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How is/was the health of your mother?
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How is/was the health of your father?
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What is your ancestry?
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What is your blood type?
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How is your sleep?
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How many hours do you sleep?
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Do you wake up often at night?
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If you do, why?
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Any pain, stiffness or swelling?
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Constipation, diarrhea or gas?
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Allergies or sensitivities? Explain
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MEDICAL INFORMATION
Do you take any supplements or medications? Please list:
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Any healers, helpers or therapies with which you are involved? Please list:
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What role do sports and exercises play in your life?
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FOOD HISTORY
What foods did you often eat as a child?
Breakfast:
Your answer
Lunch:
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Dinner:
Your answer
Snacks:
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Liquids:
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What foods do you often eat now?
Breakfast:
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Lunch:
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Dinner:
Your answer
Snacks:
Your answer
Liquids:
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Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
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Do you cook?
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What percentage of your food is home-cooked?
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Where do you get the rest of your food?
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Do you crave sugar, coffee, cigarettes or have any other major addictions?
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The most important thing I should do to improve my health is:
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ADDITIONAL COMMENTS
Anything else you would like to share?
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