Men's Health History Form - Looking Glass Natural Health

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Men's Confidential Health History Form

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Personal Information

First Name *

Last Name *

Email Address *

How often do you check email?

Home Phone

Work Phone

Mobile Phone *

Age

Height

Birthdate *

Place of Birth

Current Weight

Weight 6 months ago

Weight 1 year ago

Would you like your weight to be different?

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 best?

Any serious illnesses/hospitalizations/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 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 or therapies with which you are involved? Please list

What role do sports and exercise play in your life?

Food Information

What foods did you eat often as a child?

Breakfast

Lunch

Dinner

Snacks

Liquids

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

What is your food like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

Additional Comments

Anything else you would like to share?

Print your name *

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Warrenton VA 20186

LookingGlassNH@cs.com

540-222-5228

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