Men's Confidential Health History

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Do you take supplements or medications? Please list:

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

Other concerns or goals?

Relationship status: Children:

How is the health of your mother?

Thank you. Anything else you want to share?

At what point of life did you feel your best?

Occupation: Hours you work in a week:

Please list your main health concerns:

Do you sleep well? How many hours?

Where do you get the rest from?

What foods did you eat often as a child?

What's your food like these days?

Current weight: Weight 6 months ago:

What roles do sports and exercise play in your life?

How is the health of your father?

Do you wake at night? Why?

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

Any pain, stiffness, swelling?

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

Constipation/diarrhea/gas? Explain:

Any serious illnesses/hospitalizations/injuries?

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

What is your ancestry?

Name: Date:

Telephone:

Age: Height: Date of Birth:

What % of your food is home cooked? Do you cook?

Email:

Would you like your weight to be different? If so what?

Allergies or sensitivities? Please explain?