Men's Health History Personal Information First Name: Last Name: Address: City: State: -Select One- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas United Kingdom Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip: Email: How often do you check mail: Home Phone: Work Phone: Cell Phone: Age: Height: Birthdate: Place of Birth: Current Weight: Weight six months ago: One year ago: Would you like your weight to be different: If so, what?: Social Information Relationship status: 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 best: Any serious illness/hospitalizations/injuries: How is the health of your mother?: How is 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?: Constipation/Diarrhea/Gas?: Allergies or sensitivities? Please explain: Medical Information Do you take any supplements or medications?: Please List: Any healers, helpers, pets or therapies with which you are involved?: Please List: What role do sports and exercise play in your life?: 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?: What percentage is not?: Where do you get the rest from?: Do you crave sugar, coffee, cigarettes, or have any major addictions?: The most important thing I should change about my diet to improve my health is: Additional Comments Anything else you would like to share?: