Fitness Matrix | Queens, NY

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Men's Wellness Evaluation

First Name:

Last Name:

Email:

How often do you check email?

Daily

Hourly

Weekly

Rarely

Never

Home Phone:

Work Phone:

Mobile Phone:

Age:

Height:

Birthdate:

Place of Birth:

Current Weight:

Weight Six Months Ago:

One Year Ago:

Would you like your weight to be different?

If so, what?

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SOCIAL INFORMATION

Relationship status:

Where do you currently live?

Children:

Pets:

Occupation:

Hours of work per week:

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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?

Yes

No

How is/was the health of your mother?

How is/was the health of your father?

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:

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MEDICAL INFORMATION

Do you take any supplements or medications? Please list:

What role do sports and exercise play in your life?

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What foods did you eat often as a child?

Breakfast

Lunch

Dinner

Snacks

Liquids

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Breakfast

Lunch

Snacks

Liquids

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

Do you cook?

Yes

N

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:

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ADDITIONAL INFORMATION

Anything else you would like to share?

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