WhatShe8 Health & Wellness
About Me
Copyright
Health Coaching
My Approach
My Training
Getting Started
Free Consultation
Women’s Health History
Men’s Health History
Health History Update
Blog
Contact
WhatShe8 Health & Wellness
About Me
Copyright
Health Coaching
My Approach
My Training
Getting Started
Free Consultation
Women’s Health History
Men’s Health History
Health History Update
Blog
Contact
Men’s Health History
Personal Information
First Name:
*
Birthdate:
Last Name:
*
Place of Birth:
Email:
*
Height (inches):
Mobile Phone:
Current Weight (lbs.):
Home Phone:
Weight Six Months Ago (lbs.):
Country:
*
Weight One Year Ago (lbs.):
State or Provence:
Would you like your weight to be different?:
City or Town:
If so, what? (lbs.):
Social Information
Relationship Status:
Children:
Pets:
Occupation:
Number of Hours Worked per Week:
Health Information
Please list your main health concerns:
Other concerns and/or goals?:
At what point in your life did you feel your 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?:
How is your sleep?:
How many hours do you sleep a night?:
Do you wake up at night?:
Why do you wake up at night?:
What blood type are you?:
Constipation/Diarrhea/Gas?:
Any pain, stiffness or swelling?:
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?
What is your food like these days?
Breakfast:
Breakfast:
Lunch:
Lunch:
Dinner:
Dinner:
Snacks:
Snacks:
Liquids:
Liquids:
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?:
Do you cook?:
What percentage 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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