Health Discovery Inventory – Men

I want to thank you for taking time to complete this Health Discovery Inventory. It is designed to collect a LOT of information as we learn how to help support your efforts to obtain better health. Please be as thorough as possible with your answers so we have a really clear picture of your past and present.

Once complete, please click on the Save and Send button and I will receive it and look everything over promptly. I look forward to learning more about you and how we can help you look and feel your best!

Health Discovery Inventory - Men

Name
Best Email
How often do you check emails daily?
Phone Number
Birth Date
Place of birth:
What is your height?
What is your current weight?
What was your weight six months ago?
What was your weight one year ago?
Would you like your weight to be different? How so?

Social Information

What is your relationship status?
Do you have children?
What type of pets do you have?
Where do you currently live?
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Do you feel safe at home?
Please describe your occupation and the tasks you perform.
How many hours do you work weekly?
Please describe how you spend your days currently.
How often do you get together with friends or family?
Please share the types of social activities you are involved with:

Health Information

Please list and explain your main health concerns:
Other concerns and/or goals?
How often to you exercise weekly?
30 minutes1 hour2 hours3 hours4+ hoursI rarely have time to exercise.
Please describe the types of physical activities you are involved in weekly:
What role do sports and exercise play in your life? Why or why not?
At what point in your life did you feel best?
Any serious hospitalizations, illnesses, or injuries?
What types of chemicals have you been exposed to?
Describe the health of your mother?
Describe the health of your father?
Describe the health of your siblings?
Were you breast fed as an infant?
In what way were you delivered?
What is your ancestry?
What is your blood type?
A +/-B +/-O +/-A/B
Describe how well you sleep?
How many hours of sleep you you get typically?
Do you wake up at night? Why?
Please list any pain, stiffness, or swelling:
How often do you experience constipation, diarrhea or gas?
Please explain any allergies or sensitivities:

Medical Information

Please list any supplements or medications you are curretnly taking:
Please list any healers, helpers, or therapies with which you are involved:

Food Information - You are what you eat!

What breakfast foods did you eat often as a child? Please be as specific as possible.
What lunch foods did you eat often as a child? Please be as specific as possible.
What dinner foods did you eat often as a child? Please be as specific as possible.
What snack foods and liquids did you eat/drink often as a child? Please be as specific as possible.
What breakfast foods do you eat now? Please be as specific as possible.
What lunch foods do you eat now? Please be as specific as possible.
What dinner foods do you eat now? Please be as specific as possible.
What snacks foods and liquids do you eat/drink now? Please be as specific as possible.
Please describe your cravings and the types of foods you crave:
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? How so?
Do you cook?
What percentage of your food would you say is home-cooked?
Please explain where you get the rest of your food from? Be specific.
Do you crave sugar, coffee, cigarettes, or have any major addictions? How often?
How much coffee do you consume daily?
The most important thing I should do to improve my health is:
How committed are you to getting your optimum health back?
Please describe why you decided to consider working with a Wellness Coach.
How did you learn about One Degree Forward?

Additional Comments

Is there anything else you would like to share with me? Be as detailed as you would like.
Were there any complication during your birth? Please explain.

Verification

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Eat smart • Move more • Feel better • Live longer

Health Discovery Inventory – Men