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Men's Health History Form Please fill out this form and click the "Submit" button at the bottom of the page. Personal Information Name: Address Email How often do you check mail Home Phone Work Phone Cell 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 Children? Occupation Hours of work per week Health Information Please list your main health concerns Other concerns Any serious illness/hospitalizations/injuries How is the health of your mother? How is the health of your father? What is your ancestry? What blood type are you? Do you sleep well? How many hours? Do you wake up at night? Why? Any pain, stiffness or swelling? Constipation/Diarrhea/Gas? Medical Information Do you take any supplements or medications? Please list Any healers, helpers, pets 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's your food like these days? Breakfast Lunch Dinner Snacks Liquids   What percentage of your food is home cooked? What percentage is not? What do you get the rest from? Do you crave sugar, coffee, cigarettes or have any major additions? Additional Comments Anything else you would like to share?