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Men’s Health
Men’s Health History
Step 1 of 3 – General Info
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Date
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Email
*
Enter Email
Confirm Email
Weight (Current Weight)
*
What would you like your weight to be?
*
What would you like your weight to be?
*
What would you like your weight to be?
*
Sleep
*
I Sleep Well
I Wake Up At Night
Check all that apply.
How many hours per night do you sleep?
Relationship Status
*
Married/In A Committed Relationship
Divorced/Separated
Single
Do You Have Children?
Yes
No
Occupation
*
Hours You Work Per Week
*
List Your Main Health Concerns
*
Any Serious Illness/Hospitalizations/Injuries?
Describe Any Pain, Stiffness or Swelling
Describe Any Allergies or Sensitivities
Do You Experience Constipation/Diarrhea/Gas/Acid Reflux? Explain
How Is The Health Of Your Mother?
How Is The Health Of Your Father?
What Is Your Ancestry?
*
What Blood Type Are You?
*
A
B
AB
O
I Have No Idea
Please List Any Supplements or Medications You Take
List any Healers, Helpers, Pets Or Therapies With Which You Are Involved.
List What Role Sports And Exercise Play In Your Life
What Foods Did You Eat Often As A Child?
*
Breakfast
Lunch
Dinner
Snacks
Liquids
List 3-4 types of foods or drinks that you ate as a child for each of the following meals.
What Foods Do You Eat These Days?
*
Breakfast
Lunch
Dinner
Snacks
Liquids
List 3-4 types of foods or drinks that you currently eat for each of the following meals.
What Percentage Of Your Food Is Home Cooked?
*
Please enter a value between
0
and
100
.
Where Do You Get Your Food From That Is NOT Home Cooked?
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?
Describe At What Point In Your Life You Felt Best
The Most Important Thing I Should Change About My Diet To Improve My Health Is?
Is There Anything Else You Would Like To Share?
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