Men's Health History - Easy Gluten Free Living

Contact

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Work Phone*

Mobile Phone*

Email*

Do you check your email daily?*

Yes
No

About You

Marital Status*

Employment*

Occupation*

Hours per Week*

Children*

Please enter 'N/A' if not not applicable

Pets*

Please enter 'N/A' if not not applicable

Please list forms of exercise and frequency.*

Please enter 'N/A' if not not applicable

Basic Health

Age*

Height*

Blood Type*

Where were you born?*

Weight*

Have you lost or gained more than 3 lbs in the last 6 months? Explain:*

Are you happy with your current weight?*

Yes
No
Unsure

If no, what would you like to change?*

Please enter 'N/A' if not not applicable

Please list all supplements or medications.*

Please enter 'N/A' if not not applicable

Sleep Habits

Do you sleep through the night?*

Hours of sleep per night?*

Do you wake up at night?*

Please enter 'N/A' if not not applicable

Do you wake up at night or have trouble sleeping?*

Please enter 'N/A' if not not applicable

If yes, why?*

Please enter 'N/A' if not not applicable

Medical

Physician*

Please enter 'N/A' if not not applicable

How do you feel?*

Family Medical HIstory

How was/is your mother's health?*

How was/is your father's health?*

What is your ancestry?*

Diet

What percentage of your food is homecooked?*

Allergies or sensitivities? Please explain:*

Please enter 'N/A' if not applicable

Sugar, coffee, cigarettes?*

Please enter 'N/A' if not applicable

Constipation, diarrhea, or gas?*

Please enter 'N/A' if not applicable

Will your family and/or friends support you in your healthy changes?*

Please enter 'N/A' if not applicable

Childhood Diet

What BREAKFAST foods did you eat often as a child?*

What LUNCH foods did you eat often as a child?*

What DINNER foods did you eat often as a child?*

What SNACK OR DESSERT foods did you eat often as a child?*

What BEVERAGES did you drink often as a child?*

Current Daily Diet

What does your typical BREAKFAST consist of?*

What does your typical LUNCH consist of?*

What does your typical DINNER consist of?*

What does your typical DESSERT consist of?*

What do your typical SNACKS consist of?*

What do your typical BEVERAGES consist of?*

Health Concerns

Hospitalizations and serious injury.*

Please enter 'N/A' if not not applicable

Please list your main health concerns:*

Other concerns and/or goals?*

Please enter 'N/A' if not not applicable

What is the one thing you could do that would improve your health?*

Additional

Anything else you'd like to share?

Health History - Men's

Contact

About You

Basic Health

Sleep Habits

Medical

Family Medical HIstory

Diet

Childhood Diet

Current Daily Diet

Health Concerns

Additional