Men’s Health History Form

We're so glad you want to invest in yourself and work with a health coach! We want to make sure we can support you in the best way. All information shared is confidential.

Name

First Name

Last Name

Message

Phone

Age

Height

(in cm)

Birthday

YYYY

Place of birth

Current weight

(in kg)

Weight 6 months ago

(in kg)

Weight a year ago

(in kg)

Relationship status

Where do you currently live?

Children

Pets

Occupation

Hours of work 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/hospitilizations/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?

How is your sleep?

How many hours do you sleep?

Do you wake up at night?

Why?

Any pain, stiffness or swelling?

Constipation/ Diarrhoea/ Gas?

Allergies or sensitivities? Please explain:

Please list any supplements or medications you're currently taking:

Please list any healers, helpers or therapies with which you are involved in:

What role do sports and exercise play in your life?

What food did you often eat as a child for breakfast, lunch and dinner?

What liquids did you often drink as a child?

What is a typical food day for you these days?

What liquids do you often drink these days?

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:

Do you now or have you ever suffered from disordered eating?

Does anyone in your household suffer from disordered eating?

Anything else you would like to share?

Men’s Health History Form

No more fad diets, no more counting calories, no more feeling out of touch with your own body.