Men’s Health History All of your information will remain confidential between you and the Health Coach. Your Name *Email Address *How often do you check your email? *Home Phone Number *Work Phone Number *Cell Phone Number *Age *Height *Weight *Place of Birth *Current Weight *Weight six 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/goals? *At what point in your life did you feel best? *Any serious illnesses/hospitalizations/injuries? *How was/is the health of your mother? *How was/is the health of your father? *What is your ancestry? *What is your blood type? *How is your sleep? *How many hours do you sleep? *Do you wake up at night? *Why do you wake up at night? *Any pain, stiffness or swelling? *Constipation/Diarrhea/Gas? *Allergies or sensitivities? Please explain. *Do you take any supplements or medications? Please list. *What role do sports play in your life? *As a child, what foods did you often eat for breakfast? *As a child, what foods did you often eat for lunch? *As a child, what foods did you often eat for dinner? *As a child, what foods did you often eat for snacks? *As a child, what liquids did you often drink? *Will friends and/or family 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 breakfast diet like? *What is your lunch diet like? *What is your dinner diet like? *What snacks have you been eating? *What liquids have you been drinking? *Anything else you would like to share? *Send Message Facebook Instagram Young Living IIN Ambassador
