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Men's Health Form
First Name
Last Name
Email
How often do you check your emails?
Home Phone
Work Phone
Mobile Phone
Age
Height
Birthday
Place of birth
Current Weight
Weight 6 months ago
Weight one year ago
Would you like your weight to be different
If so, What?
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 illness/hospitalizations/injuries
How is/was the health of your mother?
How is/was the health of your father?
What is your ancestory?
What blood type are you?
How is your sleep?
How many hours do you sleep?
Do you wakeup at night?
Reasons for waking up?
Any pain stiffness or swelling
Constipation/Diarrhea/Gas?
Allergies or sensitivities?
Please explain?
Please list your supplements or medications
Any healers, helpers or therapists which you are involved? Please list:
What role do sports and exercise play in your life?
What foods did you eat often as a child: Lunch?
Breakfast
Dinner
Snacks
Liquids?
Will your family and friends be supportive in your 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?
What is your food like these days? Breakfast:
Lunch
Dinner
Snacks
Liquids
Anything else you would like to share?
Print your name
Your Signature
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