Be Healthy Now
Men's Health History


The purpose of this form is to help us understand your personal health history.
Please provide the requested information as honeslty and completely as possible to allow us to serve you best.
Personal Information
Name
Street
City
State
Zip Code
Email
Checked
Home Phone
Cell Phone
Work Phone
Age
Birth Date
Birth Place
Height
Weight
Weight on 6/ 24
Weight on 12/23
Goal Weight
Social Information
Relationship Status
Children
Occupation
Weekly Hours
Health Information
Health Concerns
Other Concerns
Serious Illnesses, Hospitalizations, Injuries
Pain, Stiffness, Swelling?
Constipation, Diarrhea, Gas?
Mother's Health Summary
Father's Health Summary
Do you sleep well?
How many hours?
Do you wake up at night?
Why?
Ancestry
Blood Type
Medical Information
List any medications or supplements you take
List any healers, helpers, pets or therapies you have
What role do sports and exercise play in your life?
Nutrition Information
What foods did you often eat as a child?
Breakfast
Lunch
Dinner
Snacks
Liquids
What foods did you often eat now?
Breakfast
Lunch
Dinner
Snacks
Liquids
% Home Cooked
Where does the rest come from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
Additional Information
Anything else you would like to share?
*Required
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