Men’s Health History Health History - Men's Men's Health History ContactName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home Phone*Work Phone*Mobile Phone*Email* Do you check your email daily?* Yes No About YouMarital Status*SingleMarriedSeparatedDivorcedWidowedOtherEmployment*Employed Full-TimeEmployed Part-TimeSelf-employedNot employed but looking for workNot employed and not looking for workHomemakerRetiredStudentPrefer Not to AnswerOccupation*Hours per Week*Children*Please enter 'N/A' if not not applicablePets*Please enter 'N/A' if not not applicablePlease list forms of exercise and frequency.*Please enter 'N/A' if not not applicableBasic HealthAge*Height*Blood Type*Where were you born?*Weight*Have you lost or gained more than 3 lbs in the last 6 months? Explain:*Are you happy with your current weight?* Yes No Unsure If no, what would you like to change?*Please enter 'N/A' if not not applicablePlease list all supplements or medications.*Please enter 'N/A' if not not applicableSleep HabitsDo you sleep through the night?*Hours of sleep per night?*Do you wake up at night?*Please enter 'N/A' if not not applicableDo you wake up at night or have trouble sleeping?*Please enter 'N/A' if not not applicableIf yes, why?*Please enter 'N/A' if not not applicableMedicalPhysician*Please enter 'N/A' if not not applicableHow do you feel?*Family Medical HIstoryHow was/is your mother's health?*How was/is your father's health?*What is your ancestry?*DietWhat percentage of your food is homecooked?*N/ALess than 10%10-20%30-40%50-60%60-70%70-80%80-90%90-100%Allergies or sensitivities? Please explain:*Please enter 'N/A' if not applicableSugar, coffee, cigarettes?*Please enter 'N/A' if not applicableConstipation, diarrhea, or gas?*Please enter 'N/A' if not applicableWill your family and/or friends support you in your healthy changes?*Please enter 'N/A' if not applicableChildhood DietWhat BREAKFAST foods did you eat often as a child?*What LUNCH foods did you eat often as a child?*What DINNER foods did you eat often as a child?*What SNACK OR DESSERT foods did you eat often as a child?*What BEVERAGES did you drink often as a child?*Current Daily DietWhat does your typical BREAKFAST consist of?*What does your typical LUNCH consist of?*What does your typical DINNER consist of?*What does your typical DESSERT consist of?*What do your typical SNACKS consist of?*What do your typical BEVERAGES consist of?*Health ConcernsHospitalizations and serious injury.*Please enter 'N/A' if not not applicablePlease list your main health concerns:*Other concerns and/or goals?*Please enter 'N/A' if not not applicableWhat is the one thing you could do that would improve your health?*AdditionalAnything else you'd like to share?