Psychotherapist, Author, Speaker

HealthJONES Health Coaching

men's Health History Form

Name

First Name

Last Name

Email Address

How often do you check email?

What's the best phone number to reach you?

Birthdate & age

Place of birth

Height

Current weight

Weight 6 months ago

Weight 1 year ago

Would you like your weight to be different?

If yes, what?

Social Information

What is your relationship status?

Where do you currently live?

Any children?

Any pets?

What is your occupation?

How many hours a week do you work?

Health Information

What are 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? If yes, why?

Any pain, stiffness or swelling?

Any constipation, diarrhea or gas?

Do you have any allergies or sensitivities? Please explain.

Medical Information

Do you take any supplements or medications? Please list below:

Any healers, helpers or therapies in which you are involved? Please list below:

What role do sports and exercise play in your life? Please explain.

Food Information

What foods did you often eat as a child?

Please share about breakfast, lunch, dinner, snacks and 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?

What is your food like these days?

Please share about breakfast, lunch, dinner, snacks and liquids.

Anything else you would like to share?

HealthJONES Health Coaching

men's Health History Form

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robin@robinstone.com

(646) 791-3307

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Men's Form

HealthJONES Health Coaching

men's Health History Form

RESOURCES

Speaking + Workshops

HealthJones Recipe Index

Blog

Contact

robin@robinstone.com

(646) 791-3307

healthjones FORMS

Revisit Form

Women's Health Form

Men's Health Form

Follow