THE PACKED PLATE
by Ashley Langer
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About
My Story
My Training
My Coaching Style
Health Coaching
Work with me
Let's Chat
Pilates
Principles
Navigation
Home
About
My Story
My Training
My Coaching Style
Health Coaching
Work with me
Let's Chat
Pilates
Principles
MEN’S HEALTH HISTORY
Name
*
First Name
Last Name
Email
*
Home Phone
*
(###)
###
####
Mobile Phone
(###)
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Work Phone
(###)
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How often do you check e-mail?
Age:
Height:
Birthdate:
MM
DD
YYYY
Place of Birth:
Current Weight:
Weight Six Months Ago:
One Year Ago:
Would you like your weight to be different?
Yes
No
If so, what is your goal weight?
SOCIAL INFORMATION
Relationship status:
Where do you currently live?
Children?
Pets?
Occupation?
Hours of work per week?
HEALTH INFORMATION
Please list your main health concerns:
Other concerns and/or goals?
At what point in your life did you feel best?
Any serious illnesses/hospitalizations/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?
Yes
No
Why?
Any pain, stiffness or swelling?
Constipation/Diarrhea/Gas?
Allergies or sensitivities? Please explain:
MEDICAL INFORMATION
Do you take any supplements or medications? Please list:
Any healers, helpers or therapies with which you are involved? Please list:
What role do sports and exercise play in your life?
FOOD INFORMATION
What foods did you eat often as a child?
Breakfast:
Lunch
Dinner
Snacks
Liquid
CURRENT FOOD INFORMATION
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Do you cook?
What percentage of your food is home-cooked?
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I should do to improve my health is:
Current Breakfast:
Current Lunch:
Current Dinner:
Current Snacks:
Current Liquids:
ADDITIONAL COMMENTS
Anything else you'd like to share?
Print Your Name
*
Thank you!