Men’s Health History All of your information will remain confidential between you and the Health Coach. If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Full Name * Email How often do you check your email Phone Age Height Birthday Place of Birth Current Weight Weight Six Months Ago Weight One Year Ago Would you like your weight to be different? If so, what? Social Information Address 1 Address 2 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code Relationship status Children Pets Occupation Hours of work per week Health Information 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? How is your sleep? How many hours? Do you wake up at night? Why? Any pain, stiffness or swelling? Constipation/Diarrhea/Gas? Allergies or sensitivities? Please explain: Medical Information Do you take any supplements or medications? Please list Any healers, helpers or therapies with which you are involved? Please list What role do sports and exercise play in your life? Food Information What foods did you eat often as a child? Breakfast Lunch Dinner Snacks Liquids Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? Do you cook? What percentage of your food is home-cooked? Where do you get the rest from? Do you crave sugar, coffee, cigarettes, or have any major addictions? The most important thing I should do to improve my health is What is your food like these days? Breakfast Lunch Dinner Snacks Liquids Additional Comments Anything else you would like to share?: