Whole and Well
Home
About
Health Coaching
Connect
Free Book
Newsletter
Blog
Forms
Clients
Please fill out the form below and then click submit when finished.
Men's Health History
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
-
-
Cell Number
*
-
-
Email
*
How often do you check email?
*
Age
*
Relationship Status
*
Children
*
Children's Ages
*
Current Height
*
Weight Six months ago
*
Weight a year ago
*
Current weight
*
Occupation
*
Number of work hours per week
*
List current health concerns
*
Other concerns or goals you would like to reach
*
At what point in your life did you feel the best ? Why?
*
Hospitalizations, Injuries, Illnesses
*
When have you taken antibiotics?
*
How was/is the health of your mother?
*
How is/was the health of your father?
*
What is your blood type?
*
Do you sleep well?
*
Yes
No
Do you wake up at night?
*
yes
no
Why do you wake up at night?
*
How many hours of sleep do you get a night?
*
Do you have any pain and stiffness in your joints?
*
Have you had a vasectomy?
*
Have you had kidney stones?
*
Yes
No
Please give approx dates and treatment
*
Do you experience burping, gas or bloating? Explain
*
Do you experience constipation? Explain
*
Do you experience diarrhea? Explain
*
How often do you have your bowel movements?
*
What color are your stools?
*
List any allergies or food intolerances
*
List current supplements
*
List current medications
*
Do you exercise? In what form and how often?
*
What role does sports and exercise play in your life?
*
List sport activities
*
List common foods for breakfast, lunch and dinner as a child
*
List common foods you ate this week including desserts and drinks
*
Are family and friends supportive of your desire to make food and or lifestyle changes?
*
What % or your food is home cooked?
*
Do you cook?
*
Never
Sometimes
Freqeuntly
Always
Love it
Avoid it at all costs
Do you crave coffee, sugar, cigarettes or have major or minor addictions? Explain
*
The most important thing I should change about my diet to improve my health is...
*
Any thing else you would like to share?
*
Submit
Thanks for taking the time to think about your health and take care of yourself.
For Whole and Well Staff only
Comment
*
Comment
*
Areas to pursue
*
Submit