Men’s Confidential Health History

Thank you for taking the time to share your health history. This information will be kept confidential and will help inform your customized plan.

Name

First Name

Last Name

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Age

Phone

(###)

###

####

Date of Birth

Place of Birth

Height

Current Weight

Weight 6 Months Ago / Weight 1 Year Ago

Would you prefer a different weight? If so, what?

Relationship Status

Children

Pets

Occupation

Hours of Work Per Week

Main Health Concerns and/or Goals?

At what point in your life did you feel your best?

Do you sleep well?

Do you sleep well? How many hours do you sleep per night? Do you wake up at night?

Any Constipation/Diarrhea/Gas?

Any Allergies or sensitivities?

Please list any supplements or medications you take

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

What role does sports and exercise play in your life?

What foods did you eat often as a child?

Please include examples of Breakfast, Lunch, Dinner, Snacks and Liquids

What’s your food like these days?

Please include examples of Breakfast, Lunch, Dinner, Snacks and Liquids

What percentage of your food is home cooked?

What percentage of your food is home cooked? Do you cook? Where do you get the rest of your food from?

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

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

Anything else you'd like to share?