Men’s Health History

1. Personal Information
2. Your Name(required)
3. Address(required)
4. Email(valid email required)
5. How often do you check e-mail(required)
6. Home Phone(required)
7. Cell Phone(required)
8. Birthdate(required)
9. Place of Birth(required)
10. Height(required)
11. Current Weight(required)
12. Weight six months ago(required)
13. One year ago(required)
14. Would you like your weight to be different(required)
15. If so, what?
16. Social Information
17. Relationship status(required)
18. Children(required)
19. Pets?(required)
20. Occupation(required)
21. Hours of work per week(required)
22. Health Information
23. Please list your main health concerns(required)
24. Other concerns / goals?(required)
25. At what point in your life did you feel best(required)
26. Any serious illness / hospitalizations / injuries(required)
27. How is / was the health of your mother?(required)
28. How is / was the health of your father?(required)
29. What is your ancestry?(required)
30. What blood type are you?(required)
31. How many hours do you sleep?(required)
32. Do you wake up at night?(required)
33. Any pain, stiffness or swelling?(required)
34. Constipation / Diarrhea / Gas?(required)
35. Allergies / sensitivities?(required)
36. If so, please explain(required)
37. Medical Information
38. Do you take any supplements or medications?(required)
39. If so, please list
40. Any healers, helpers, pets or therapies with which you are involved?(required)
41. If so, please list
42. What role do sports and exercise play in your life?(required)
43. Food Information
44. What foods did you eat often as a child?
45. Breakfast(required)
46. Lunch(required)
47. Dinner(required)
48. Snacks(required)
49. Liquids(required)
50. What's your food like these days?
51. Breakfast(required)
52. Lunch(required)
53. Dinner(required)
54. Snacks(required)
55. Liquids(required)
56. Will family / friends be supportive of your desire to make food / ifestyle changes?(required)
57. Do you cook?(required)
58. What percentage of your food is home cooked?(required)
59. What percentage is not?(required)
60. Where do you get the rest from?(required)
61. Do you crave sugar, coffee, cigarettes, or have any major addictions?(required)
62. The most important thing I should change about my diet to improve my health is(required)
63. Additional Comments
64. Anything else you would like to share?
65. Enter Code

 

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