Men's Health Coaching Intake Form - Functional Medicine Doctor

Thank you for your interest in Health Coaching at Sharlin Health!

Please fill out the form below to get started.

Personal Information

First Name *

Last Name *

Email *

How often do you check your email? *

Home *

Mobile

Age

Height

Birthdate

Place of Birth

Current Weight

Weight 6 months ago

Weight 1 year ago

Would you like your weight to be different?

Yes No

What would you like your weight to be?

Social Information

Relationship Status

Where do you currently live?

Children

Yes No

Pets

Yes No

Occupation

Hours of work per week?

Health Information

Please list your main health concerns

Other concerns or goals

At what point in your life did you feel best?

Any serious illnesses, hospitalizations, or injuries?

How is/was the health of your mother?

How is/was the health of your father?

What is your ancestry?

What is your blood type?

How is your sleep?

How many hours do you sleep on average per night?

Do you wake up at night?

If you wake up at night, why?

Any pain, stiffness, or swelling?

Do you experience constipation, diarrhea, or gas?

Do you have any 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 for Breakfast?

What foods did you eat often as a child for Lunch?

What foods did you eat often as a child for Dinner?

What foods did you eat often as a child for Snacks?

What liquids did you consume often as a child?

What is your food like currently? (Breakfast)

What is your food like currently? (Lunch)

What is your food like currently? (Dinner)

What is your food like currently? (Snacks)

What liquids do you consume most often currently?

Will family and friends be supportive of your desire to make food and lifestyle changes?

Do you cook?

Yes No

What percentage of your food is home-cooked?

Where do you get the rest of your food from?

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

The most important thing I should do to improve my health is

Additional Information

Anything else you would like to share?

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