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Personal Information
Men's Health History
Women's Health History
Home
About
My Story
My Background
Contact
The Plan
Core Services
Program Details
Concepts
Contact
Blog
Blog
Recipes
Take Action
Personal Information
Men's Health History
Women's Health History
Take Action
Personal Information
Men's Health History
Women's Health History
men's health history
Name
*
First Name
Last Name
Email Address
*
How often do you check e-mail?
Home Phone
(###)
###
####
Work Phone
(###)
###
####
Mobile Phone
(###)
###
####
Age:
Height:
Birthdate:
*
MM
DD
YYYY
Place of Birth:
Current Weight:
Weight (6 months ago):
Weight (1 year ago):
Would you like your weight to be different?:
If so, what?
SOCIAL INFORMATION
Relationship Status:
Where do you currently live?:
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/hospitalization/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? What is 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 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:
Additional comments
Anything else you like to share?:
Thank you!