Men's Confidential Health History
Name *

Address

Email Address *

How often do you check email?

Age

Height

Date of Birth

Place of Birth

Would you like your weight to be different? YesNo
If so, What?

Occupation

Hours of work per week

Please list your main health concerns *

Other Concern and/or Goals

At what point in your life did you feel best?

Any Serious illnesses/hospitalizations/injuries?
YesNo

How is the health of your father?

How is the health of your mother?

What is your Ancestry?

What Blood Type Are You?

Why?

Any Pain, stiffness or swelling?

Constipation/Diarrhea/Gas?
YesNo
Expain

Allergies or Sensitivities? Please Explain:

Do you take any suppliments or medications? Please list: *

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?

Breakfast

Lunch

Dinner

Snacks

Liquids

What's your food like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

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

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

What percentage of your food is home cooked?

Do you cook?
YesNo

Where do you get the rest from?

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

Anything you want to share?