Confidential Health History (Male)

Personal Information

Name*

First Last

Address*

Street Address City State ZIP Code

Email*

Enter Email Confirm Email

Work Phone

Home Phone*

Cell Phone

Date of Birth*

Place of Birth*

Age*

Height*

Current Weight*

Weight 6 Months Ago*

Weight 1 Year Ago*

Would you like your weight to be different?*

Yes
No

What would you like your weight to be?*

Social Information

Relationship Status*

Children?*

Pets?*

Occupation*

Hours of work per week*

Health Information

Do you sleep well?*

When do you get up in the morning?*

Do you wake at night?*

What times?

To urinate?

Constipation/Diarrhea?*

Yes
No

Please explain

What blood type are you?*

What is your ancestry?*

What are your chief concern and goals?*

Have you ever taken hormones?*

Have you ever taken anabolic steroids?*

Medical Information

Do you take supplements or medications?*

Yes
No

Please describe

Are there any healers, helpers or therapists with which you are involved?*

Yes
No

Please list

What role does exercise play in your life?*

Do you drink coffee, smoke cigarettes, or have any major addiction?*

What % of your food is home cooked?*

Where do you get the rest from?*

Serious illness/hospitalizations/injuries?*

How is the health of your mother?*

How is the health of your father?*

Diet Information

What foods did you eat often as a child?

Breakfast*

Lunch*

Dinner*

Snacks*

Liquids*

What about one year ago?

Breakfast*

Lunch*

Dinner*

Snacks*

Liquids*

What's your food like these days?

Breakfast*

Lunch*

Dinner*

Snacks*

Liquids*

Confidential Health History (Male)

Personal Information

Social Information

Health Information

Medical Information

Diet Information

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