Health History Form – Men Health History Intake FormDate Personal InformationFirst and Last name *Email *How often do you check your email? *Home Phone *Work Phone Mobil Phone *Age *Height *Birth Date *Current weight *Weight 6 months ago Weight 1 year ago Would you like your weight to be different? YesNoIf so, what? *Social InformationRelationship Status *Where do you currently live? Children? Pets? Occupation? Number of hours per week? Health InformationPlease list your top 5 health concerns: Please list in order of importance. What were the specifics of those issues?Other concerns and/or goals? At what point in your life did you feel best? 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? ABO+/-ABHow is your sleep? *Select all that apply.Excellent, I never have a problem.I wake up 1-2 times per night.I can't fall asleepI wake up more than 2 times per nightI wake up between 1am and 4am a lotI can't stay asleepHow many hours? Why do you wake up at night? Any pain, stiffness, or swelling? Constipation/Diarrhea/Gas? Allergies or sensitivities? Please explain: *Libido, low or normal? Please Explain. Medical InformationAny serious illnesses/ hospitalizations/ injuries? Have you had a round of antibiotics? If so, when and how long? *Were you a C-section? *YesNoI don't knowDo you take any supplements or medications? Please list: *Any healers, helpers, or therapies with which you are involved? Please list: *Massage, Naturopath, Chiropractor, Acupuncture, Reiki, Counceling, Other Therapies, etc.What role do sports and exercise play in your life? What types of past injuries are holding you back from working out or optimizing your health? Are you working out and not seeing the results you think you should see? Food InformationWhat foods did you eat often as a child?Breakfast? Lunch? Dinner? Snacks? Liquid? 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? yesnoDo you cook? yesnoWhat 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: Who else is involved in making your health decisions? *Please list relationship and name.If the issues persisted what would be the cost to them personally? *confidence, finances, energy, happiness, joy, peace of mind, etc...Where are you on the scale of 1-10 to fix your health concerns? *What is your level of urgency to fix your health concerns? *Urgent, I think about it dailyModerate, I think about them but don't know enough to changeLow, I want to change but i'm not sure i'm readyWhat is your level of commitment to fixing your health concern? Scale of 1-10.When was the last time you faced a difficult situation and worked through it? *Please explain.Anything else you would like to share? *Anything, about your health or concerns, that would be beneficial for me to know.What does your ideal body and healthy life look like? *Please explain. VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank: There was an issue loading your exit LeadBox™. Please check plugin settings.