Curated by Rupina Meer

Men’s Health Intake

All of your information will remain confidential between you and the Health Coach.

Name:
Address:
Email address:
How often do you check email?
Home Phone:
Work Phone:
Mobile Phone:

Age:
Height:
Birthdate:
Place of Birth:
Current weight:
Weight six months ago:
One year ago:
Would you like your weight to be different?:
If so, what?:

Social Information

Relationship status:
Where do you currently live?:
Children:
Pets:
Occupation:
Hours of work per week:

Health Information

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/was the health of your mother?:
How is/was the health of your father?:
What is your ancestry?:

What blood type are you?:
How is your sleep?:
How many hours?:
Do you wake up at night?:
Why?:
Any pain, stiffness or swelling?:
Constipation/Diarrhea/Gas?:
Allergies or sensitivities? Please explain:

Medical Information

Do you take any supplements or medications? Please list:
Any healers, helpers or therapies with which you are involved? Please list:
What role do sports and exercise play in your life?:

Food Information

What foods did you eat often as a child?

Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:

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?:
Do you cook?:
What 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:

Additional Comments

Anything else you would like to share?: