MEN'S HEALTH FORM — TEACH.EAT.REPEAT...

PERSOAL INFORMATION

Name

First Name

Last Name

How often do you check e-mail?:

HOME PHONE

(###)

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WORK PHONE

(###)

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MOBILE PHONE

(###)

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AGE:

HEIGHT

BIRTHDATE:

YYYY

PLACE OF BIRTH:

CURRENT WEIGHT:

Current, 6 months ago and 1 year ago.

Would you like your weight to be different?:

If yes, what's your goal weight?

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 your best?

Any serious illnesses/hospitalizations/injuries?

How is/was the health of your Mother and Father?

What is your ancestry?

What is your blood type?

How is your sleep?

Please list 1) How many hours? 2) Do you wake up at night? 3) If so, 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:

What role do sports and exercise play in your life?

FOOD INFORMATION

What foods did you eat often as a child?

Please list Breakfast, Lunch, Dinner and Snacks.

What is your food like these days?

Please list Breakfast, Lunch and Dinner.

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:

Please list Breakfast, Lunch and Dinner, Snacks and Liquids.

ADDITIONAL COMMENTS

Anything else you would like to share?: