All of your information will remain confidential between you and the Health Coach. Men's Health Personal InformationName* First Last Email* How often do you check e-mail:Home PhoneWork PhoneMobile PhoneAgeHeightBirthdate Place of birthCurrent WeightWeight six months agoOne year agoWould you like your weight to be different?:If so, What?Social InformationRelationship statusWhere do you currently live?ChildrenPetsOccupationHours of work per weekHealth InformationPlease list your main health concernsOther concerns and/or goals?At what point in your life did you feel best?Any serious illnesses/hospitalisations/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 InformationWhat foods did you eat often as a child? BREAKFASTWhat foods did you eat often as a child? LUNCHWhat foods did you eat often as a child? DINNERSnacksLiquidsWill 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:What is your food like these days? BREAKFASTWhat is your food like these days? LUNCHWhat is your food like these days? DINNERSnacksLiquidsAdditional CommetsAnything else you would like to share?