Program Forms Health History for Men

PROGRAM FORMS / HEALTH HISTORY FOR MEN

Before our scheduled meeting, please fill out and submit the form below. It's best to have this form filled out at least the day before our meeting so I have a chance to review it.

During our meeting we will review this form together, and discuss if the Thrive Program is a good fit for you.

All of your information will remain confidential between you and your Health Coach.

Personal Information

First nameLast nameEmailHow often do you check your email?Mobile phone numberAgeHeightBirthdayPlace of birthWhere did you grow up?Current weightWeight six months agoWeight one year agoWould you like your weight to be different?If so, what would be your ideal weight?

Social Information

Relationship statusWhere do you currently live?ChildrenPetsOccupationHours of work per week

Health Information

Please list your main health concernsOther 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?Were you born c-section?How is your sleep?How many hours?Do you wake up at night?If so, why?Do you experience any pain, stiffness, or swelling? If so, please explainConstipation/Diarrhea/Gas/Gastrointestinal issues?Allergies or sensitivities?

Medical Information

Please list any supplements or medications you are currently takingApproximate date you last took antibioticsAge when you first took antibioticsPlease list any healers, helpers, doctors, or therapies with which you are involvedIs there anyone you’ve listed above who you’d like to be involved in our process?What types of physical activity do you do, and how often?

Food Information

List what foods you eat on your MOST healthy day:BreakfastLunchDinnerSnacksLiquidsList what foods you eat on your LEAST healthy day:BreakfastLunchDinnerSnacksLiquidsWhat foods did you eat often as a child?BreakfastLunchDinnerSnacksLiquidsWho in your life will 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 addictions?The most important thing I should do to improve my health isWhat have you tried in the past that didn’t work?

Wellness Information

What would being healthy look like to you?Rate each of the categories below on a scale of 1-10, where 1 is not at all comfortable with where you stand, and 10 is very satisfied with where you are:RelationshipsPhysical ActivityCareerSpiritualityI define “self-care” asList the types of self-care you currently partake inDailyWeeklyMonthlyAnything else you would like to share?

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