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Men’s Confidential Health History Form
Please fill-out the form below.
Step 1 of 3
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Name:
First
Last
Address:
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Email Address:
How often do you check email?
Work Phone Number:
Home Phone Number:
Mobile Phone Number:
*
Age:
Height:
Date of Birth:
Place of Birth:
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Current Weight:
Weight 6 Months Ago:
Weight One Year Ago:
Would you like your weight to be different?
No
Yes
If so, what?
Relationship Status:
Single
Married
Divorced
Seperated
Widow
Children:
No
Yes
Pets:
No
Yes
Occupation:
Hours 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?
No
Yes
Please list illnesses/hospitalizations/injuries?
How is/was the health of your mother?
Below Average
Average
Above Average
How is/was the health of your father?
Below Average
Average
Above Average
What is your ancestry?
What blood type are you?
Do you sleep well?
No
Yes
How many hours?
Do you wake up at night?
No
Yes
Why?
Any pain, stiffness or swelling?
No
Yes
Any Constipation/Diarrhea/Gas?
No
Yes
Please explain:
Any Allergies or Sensitivities?
No
Yes
Please explain:
Do you take any supplements or medications?
No
Yes
Please list:
Press the "+" symbol to list more.
One
Two
Three
Any healers, helpers or therapies with which you are involved?
No
Yes
Please list:
Press the "+" symbol to list more.
One
Two
Three
What role does sports and exercise play in your life?
Not Important
Important
Very Important
Do you crave sugar, coffee, cigarettes, or have any major addictions?
No
Yes
What foods did you eat often as a child?
Please list foods for the following. Breakfast, Lunch, Dinner, Snacks & Liquids
What’s your food like these days?
Please list foods for the following. Breakfast, Lunch, Dinner, Snacks & Liquids
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
No
Yes
What percentage of your food is home cooked?
Do you cook?
No
Yes
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?
Name
This field is for validation purposes and should be left unchanged.
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