Men's Health History Form

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 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.

Men's Health History

For Whole and Well Staff only