Lisa Fabry Nutrition & Yoga Therapy
Client Information Form
General Health: Men
Date of birth
Phone number (inc country and area code)
Other medical practitioners you see
Do you have any current medically diagnosed conditions or injuries?
What are your three main health goals?
Has your weight increased or decreased in the last year?
Please list all medication you take, including prescribed drugs, over-the-counter medicines and supplements.
Have you ever experienced a hypersensitivity reaction to any medication or remedy?
Do you have any known allergies or sensitivities?
FAMILY HEALTH HISTORY
PERSONAL HEALTH HISTORY
PLEASE DESCRIBE ANY SYMPTOMS YOU CURRENTLY HAVE
Anything else not mentioned?
Please list any significant events in your life, which could have impacted your health.
MEN: Reproductive and Sexual Health
Have you noticed any change in the strength of the flow or urine or ability to stop or start the flow?
If yes, when did you first notice this?
Do you have any pain or discomfort in the reproductive areas?
Do you have any problems maintaining an erection?
Do you have any concerns about your sexual health?