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Holistic Health & Lifestyle Coaching | Men's Health History | Empower Yourself 4 Health
Laurie Zacco
Theresa Pierce

Men’s Health History

All of your information will remain confidential between you and the Health Coach.

    Personal Information

    First Name: *

    Last Name: *

    Email: *

    How often do you check e-mail:

    Home Phone:

    Work Phone:

    Mobile 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:

    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:

    What is your food like these days?

    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:


    Additional Comments

    Anything else you would like to share?:

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