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Men Health History 4 Better Health
*Please fill this Confidential Health History form out and send it back to me 2-3 days PRIOR to your consultation. This will offer you the best value during our interview.* Name: __________________________________________________ Date: _______________ DOB: _______ Address: _________________________________________ ZIP CODE: __________ Home# ____________________________ Cell # ______________________________ Email: ____________________________________________________________________________________ Occupation: _______________________Hours/week _____ Employer: _______________________________ Name of partner/spouse: __________________________________ Marital Status: ____________________ List the ages and names of your children and step children __________________________________________________________________________________________ __________________________________________________________________________________________ Have you seen a Health Coach before? (Y/N) When? ____________________________________________ How was the experience? _________________________________________________________________ What is your primary health concern or main reason for coming today? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ When did your symptoms or health concern start? _________________________________________________________________________________________ Describe your symptoms: ____________________________________________________________________ __________________________________________________________________________________________ What seems to make it better? _________________________________________________________________ What makes it worse? _______________________________________________________________________ Are there related symptoms? __________________________________________________________________ List in order of importance other health problems/concerns that are troubling you: *What do you feel/think is causing your health concern(s)? 1. ___________________________________ since: _____________causes*: __________________________ 2. ___________________________________ since: _____________causes*: __________________________ 3. ___________________________________ since: _____________causes*: __________________________ 4. ___________________________________ since: _____________causes*: __________________________ How would you describe your general state of health? Excellent___ good___ fair___ poor___ How would you describe your parents’ state of health? Excellent___ good___ fair___ poor___ (explain) __________________________________________________________________________________________ __________________________________________________________________________________________ Are you currently under the care of any Health care practitioners? (check all that apply) Other: _______________________________________________________________________________ 1 When do you last remember feeling really great? __________________________________________________ How long do you think it’ll take to improve your health concerns? _________________ **When you’re thinking of how soon you want results, consider how long you’ve had the condition.** Date of last physical: _________________________ Name of medical doctor: _______________________________ Tel: ________________ Have you had any accidents, conditions, illnesses, injuries, surgeries or hospitalizations which affected your health in such a manner that you’ve never been totally well since? Y/N If so, please list the type of condition and the approximate date it occurred: __________________________________________________________________________________________ __________________________________________________________________________________________ Quite often my clients need lab work for data we will use for the healing journey. Are you willing to have more Occasionally insurance companies decline claims for non-traditional testing. If this were the case with you; are you willing to pay out of pocket? Yes _____ No _____ Have you used or are you currently using any of the following? Indicate (Y/N), the name, frequency and length • Laxatives - Antidiarrheal ______________________________________________________________ • Antacid - bloating ____________________________________________________________________ • Antibiotics: __________________________________________________________________________ • Probiotics ___________________________________________________________________________ • Corticosteroid creams or pills: ___________________________________________________________ • Pain killers (aspirin, Tylenol, ibuprofen, narcotics, etc.): ______________________________________ • Thyroid medication: ___________________________________________________________________ • Iron, folate, B12 ______________________________________________________________________ • Sleeping aides: _______________________________________________________________________ • Recreational drugs: ___________________________________________________________________ • Nasal sprays/allergy pills: ______________________________________________________________ Have you ever had allergy testing done? ____________ Was it blood, stool or skin patch testing? ___________ __________________________________________________________________________________________ __________________________________________________________________________________________ Please list all medication(s) not mentioned above, the amount you’re taking and the __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ List vitamins/minerals/supplements/herbs/remedies you’re taking, amount(s), and reason: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ What is your height ___________ Weight _________ Weight 6 months ago __________ Weight 1 year ago _______________ Goal weight _____________ Any weight concerns? (now/past) (gained/lost) __________________________________________________________________________________________ What have you tried to gain/lose weight? __________________________________________________________________________________________ How many meals do you have/day? _________ Do you skip meals? ___________________________________ Do you have any complaints with your digestion? _________________________________________________ How often do you have a bowel movement? _____________________________________________________ Are your bowels ___ hard___ loose ___ combination___ neither (“regular”) ___________________________ How is your sleep? __________________ Difficulty falling asleep?________ Waking in the night? _________ Bed time: _______ Rising time: _______ Do you feel rested when you wake up? ______________ How many hours of sleep do you get each night? _____ Are your sleep habits regular? ___________________________ How often do you wake in the night to urinate? ____________________________________ What else wakes you at night? _________________________________________________ Any dreams (recurrent/not) or nightmares? ______________________________________ What’s your energy level (1-10; 10=high)? _______________________________________ Do you meditate or use relaxation techniques? ___________________ How often? _______ Results? _______ Have you tried Yoga or Tai Chi in the past? _________________ How often? __________ Results? _________ Do you enjoy your work? ____________________ Do you take vacations? ____________ Do you follow any religious or spiritual/peaceful practice? _______ Please specify: __________________________________________________________________________________________ __________________________________________________________________________________________ What do you enjoy most in your life? ______________________________Do you have time for this? _______ What do you worry most about in life? _________________________________________________________ What is your stress level (1-10; 10==high)? _________What are the things that you find stressful in your life? _________________________________________________________________________________________ Is your Mom alive Y N How old is she now or was she when she passed? ______ What medical struggles did she have? ______________________________________________________________________________ Is your Dad alive Y N How old is he now or was he when he passed? ______ What medical struggles did he have? ______________________________________________________________________________ Who lives with you? ______________________________ Are they supportive of you working with a health coach? __________________________________________________________________________________ How many siblings do you have? _____ What is their health like? __________________________________________________________________________________________ Are there any other family health conditions you worry may effect you? (who had this?) __________________________________________________________________________________________ List types, ages and names of pets _____________________________________________________________ What role does sports and exercise play in your life? _____________ What is your typical sports or exercise each week? _______________________________________________________________________________ How many glasses of each do you have daily? (0-10) Water ______ Coffee ______ Tea ______ Energy drink _____ Milk ______ Sports drink _____ Juice ______ Wine _____ Beer ______ Mixed drink ______ 3 What percentage of your food is cooked at home? ______________% Where do you get the rest from? ______________________________________________________________ Breakfast ______________________________________________________________________________ Lunch _________________________________________________________________________________ Dinner ________________________________________________________________________________ How does this vary from how you ate as a child? _______________________________________________ Do you crave sugar, coffee, cigarettes, or have any major addictions? When? __________________________________________________________________________________________ What relationships in your life are satisfying? ___________________________________________________ _________________________________________________________________________________________ Do you have any relationships that are challenging or difficult? __________________________________________________________________________________________ How would you describe your relationship(s) with your partner/ children/ parent(s)/employer? _________________________________________________________________________________________ Has there been any traumatic experience or major loss in your life? ___________________________________ __________________________________________ Age at time of trauma: _____________ Where have you last traveled outside of Canada/US? ______________________________________________ _______________________________________________________When? ____________________________ Have you been exposed to toxic chemicals (from home/where you live/work: paints, industrial cleaners, pesticides, orchards, golf courses, water)? __________________________________________________________________________________________ Have you ever been tested for toxins or heavy metals? ______________________________________________ Have you ever lived in a home with smokers? If so, when? __________________________________________ Have you ever had silver fillings put in your teeth? If so, when? ______________________________________ Have you ever had silver fillings replaced? If so, when? ____________________________________________ Have you ever had reactions to any vaccinations, medications, or supplements? If yes, what and when? __________________________________________________________________________________________ __________________________________________________________________________________________ Have you suffered with recurrent yeast or skin infections? ________ what did you treat those with and when? __________________________________________________________________________________________ Are there any incidents of physical, emotional or sexual abuse in your past? __________________________________________________________________________________________ Have you experienced trouble with intimacy? ______ please explain __________________________________ Is there anything else you would like to share? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Who can I thank for referring you 4 Better Health? ________________________________________________ Once form is complete, save it to your PC, and Thank you for your time. This information is valuable 4 Better Health!

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