****Please copy, paste and email to lnraske@gmail.com***

Men’s Confidential Health History

Please write or print clearly

Name:      

    

Address:

Email address:

How often do you check email?

Telephone – Work:

Home:

Cell:

Age:

Height:

Date of Birth:

Place of Birth:

Current weight:

Weight six months ago:

One year ago:

Would you like your weight to be different?

If so, what?

Relationship status:

Children:

Pets:

Occupation:

Hours of work per week:

Please list your main health concerns:

Other concerns and/or goals?

At what point in your life did you feel best?

Any serious illnesses/hospitalizations/injuries?

How is the health of your father?

How is the health of your mother?

What is your ancestry?

What blood type are you?

Do you sleep well?

How many hours?

Do you wake up at night?

Why?

Any pain, stiffness or swelling?

Constipation/Diarrhea/Gas?

Explain:

Allergies or sensitivities? Please explain:

Do you take any supplements or medications? Please list:

Any healers, helpers or therapies with which you are involved?  Please list:

What role does sports and exercise play in your life?

What foods did you eat often as a child?

Breakfast                                                Lunch                                                        Dinner                                                   Snacks

Liquids

What’s 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 crave sugar, coffee, cigarettes, or have any major addictions?

What percentage of your food is home cooked?

Do you cook?

Where do you get the rest from?

The most important thing I should change about my diet to improve my health is:

Anything else you want to share?