Men’s Health History

Men's Health History

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

Personal Information

Would you like your weight to be different?:

Social Information

Health Information

Please list your main health concerns:

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?

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?:

The most important thing I should do to improve my health is:

What is your food like these days?

Additional Comments

Anything else you would like to share?: