Men’s Confidential Health History - N'SHAPEwithN

Health_History_Form_Women

Men’s Confidential Health History Form

Please fill-out the form below.

Step 1 of 3

33%

Name:
First Last
Address:
Street Address Address Line 2 City State ZIP Code
Email Address:
How often do you check email?
Work Phone Number:
Home Phone Number:
Mobile Phone Number:*
Age:
Height:
Date of Birth:
Date Format: MM slash DD slash YYYY
Place of Birth:
City State
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:
Children:
Pets:
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?

Save and Continue Later

Any serious illnesses/hospitalizations/injuries?
Please list 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?
Do you sleep well?
How many hours?
Do you wake up at night?
Why?
Any pain, stiffness or swelling?
Any Constipation/Diarrhea/Gas?
Please explain:
Any Allergies or Sensitivities?
Please explain:
Do you take any supplements or medications?
Please list:
Press the "+" symbol to list more.
One Two Three
Any healers, helpers or therapies with which you are involved?
Please list:
Press the "+" symbol to list more.
One Two Three

Save and Continue Later

What role does sports and exercise play in your life?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
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?
What percentage of your food is home cooked?
Do you cook?
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.

Save and Continue Later