Men's Health History
Personal Information
First Name
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Last Name
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Email Address
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Home Phone
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Mobile Phone
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Age
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Height
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Birthday
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 be different?
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If so, what?
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Social Information
Relationship status
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Where do you currently live?
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Children? Names/Ages
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Pets? Names/Ages
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Occupation
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Hours of work each week
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Health Information
Please list your main health concerns:
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Please list any other concerns and/or goals?
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At what point in your life 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?
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Do you have any pain, stiffness, swelling?
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Constipation, diarrhea or gas?
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Allergies or sensitivities?
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Medical Information
Do you take any supplements/medications?
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Are you involved with any healers, helpers, therapies?
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What role does exercise/sports play in your life?
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Food Information
What foods did you eat as a child? Give examples of breakfast, lunch, dinner, snacks:
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Will your family/friends be supportive of your desire to make food and/or lifestyle changes in your life?
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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 from?
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Do you crave sugar, coffee, cigarettes, any other addictions?
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What has your food been like over the last month? Give examples of breakfast, lunch, dinner snacks:
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Additional Information
Additional comments
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