Men’s Health

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

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Personal Information

Please enter a number from 0 to 150.
Would you like your weight to be different?*

Social Information

Please enter a number from 0 to 100.

Health Information

Please enter a number from 1 to 24.
Any pain, stiffness or swelling?:*

Food Information

What foods did you eat often as a child?
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?:*

Do you crave sugar, coffee, cigarettes, or have any major addictions?:*

What is your food like these days?

Additional Comments

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