Sustainable | Healthy | Living

Health History Forms

MEN's Health History Form

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

How often do you check email?

Message

Phone Work

Phone Home

Cell

Age

Height

Date of Birth

Place of Birth

Current Weight

Weight six months ago

One year ago

Would you like your weight to be different?

If so, what?

Relationship status

Children

Pets

Occupation

Hours of work per week

Please list your main health concerns

Other concerns and/or goals?

At what point in your life did you feel best?

Any serious illnesses/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? If so, why?

Any pain, stiffness, or swelling?

Constipation/Diarrhea/Gas? Please explain:

Allergies or sensitivities? Please explain:

Do you take any supplements or medications? Please explain:

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

What role does sports and exercise play in your life?

What foods did you eat often as a child?

For breakfast, lunch, dinner, snacks, and liquids.

What's your food like these days?

For breakfast, lunch, dinner, snacks, and liquids.

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

What percentage of your food is home cooked?

Do you cook?

Where do you get the rest of your meals/food from?

What percentage of your foods are raw fruits/veggies/juices?

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

How much water do you drink on average?

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

Anything else you want to share?