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Health History for Men
HEALTH HISTORY FOR MEN
All of your information will remain confidential between you and Raw Doreen.
How often do you check email?
Place of Birth:
Weight Six Months Ago:
Weight One Year Ago:
In what way would you like your weight to be different?
Hours Worked Per Week:
What are your main health concerns?
What blood type are you?
Other concerns or goals:
Do you sleep well?
At what point in your life did you feel best?
How many hours do you sleep?
Have you had any serious illness, hospitalizations, injuries?
Do you wake up at night and if so, why?
How is/was the health of your mother?
Do you have any pain, stiffness, or swelling?
How is/was the health of your father?
Do you have any constipation, diarrhea, or gas?
What is your ancestry?
Allergies or sensitivities? Please explain:
Do you experience yeast infections or urinary tract infections? Please explain:
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?
What foods did you eat often as a child?
What are your foods like these days?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Do you cook?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
What percentage of your food is home cooked?
The most important thing I should change about my diet to improve my health is:
Where do you get the rest of your foods from?
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