Men's Health History
All of your information will remain confidential between you and the Health Coach.
First Name:
Last Name:
Email:
How often do you check e-mail:
Green Machine
H E A L T H
CSL
Personal Information
Home Phone:
Work Phone:
Cell Phone:
Age:
Height:
Date of Birth:
Place of Birth:
Current weight:
Weight six months ago:
One year ago:
Would you like your weight to be different?:
If so, what?:
Relarionship status:
Where do you currently live?:
Children:
Pets:
Social Information
Occupation:
Hours of work per week:
Please list your main health concerns:
Health Information
Other concerns and/or goals?:
At what point in your life did you feel best?:
Any serious illnesses/hospitalizations/surgeries/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:
Do you experience yeast infections like jock itch, athletes foot or urinary tract infections? Please explain:
Do you take any vitamins, supplements or medications? Please list:
Medical Information
Any healers, helpers or therapies with which you are involved? Please list:
What role do sports and exercise play in your life?:
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?:
Food Information
What foods did you eat often as a child?
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:
What foods do you eat now as an adult?
Do you cook?:
What percentage of your food is home-cooked?:
Where do you get the rest of your food from?:
Catherine Stewart-Lindley | Green Machine Health
greenmachinehealth@gmail.com | 917-699-8790
© 2018 Catherine Stewart-Lindley. All rights reserved.
Have you had any exposure to toxins/heavy metals? Have you ever had silver amalgam fillings?:
Do you crave sugar, coffee, cigarettes, or have any major addictions?:
The most important thing I want to change to improve my health is:
Anything else you would like to share?:
Additional Comments
If you are doing this program with a partner / spouse, what portion of our work may I share with him / her?:
What percentage of your diet is organic?:
