Your health is your most important asset


Men's Health History


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



Men's Health History

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

Personal Information
Social Information
Health Information
Medical Information
Food Information

What foods did you eat often as a child?

What is your food like these days?

Additional Comments

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Draw your signature

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Legal Disclaimer:



Health/Wellness coaching is not intended to diagnose, prevent, treat or cure any disease or condition. It is not intended to substitute for the advise, treatment and/or diagnosis of a qualified licensed professional. Trained Health/Wellness Coaches may not make any medical diagnoses, claims and/or substitute for your personal physician's care. A Health/Wellness Coach may not in any way alter your medications. As your Health/Wellness Coach I do not provide a second opinion or in any way attempt to alter the treatment plans or therapeutic goals/recommendations of your personal physician. It is my role to partner with you to provide ongoing support and accountability as you create an action plan to meet and maintain your health goals.

If you are having a health emergency or crisis, whether it is physical or mental, do not call your Health/Wellness Coach. Call your local 911 or seek help from a medical professional or health care facility.

By signing the attached forms you are agreeing that you are at least eighteen (18) years of age.

All information you share with me will be kept strictly confidential. I will not share your information without your written permission.


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