Lisa Fabry Nutrition & Yoga Therapy
Client Information Form
General Health: Men
GENERAL DETAILS
Name
Today's date
Date of birth
Address
Email
Phone number (inc country and area code)
Occupation
Emergency contact
Other medical practitioners you see
Health fund
CURRENT HEALTH
Do you have any current medically diagnosed conditions or injuries?
What are your three main health goals?
Height
Weight
Waist circumference
Has your weight increased or decreased in the last year?
CURRENT MEDICATION
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
Father
Mother
Grandparents
Siblings
PERSONAL HEALTH HISTORY
PLEASE DESCRIBE ANY SYMPTOMS YOU CURRENTLY HAVE
Digestive
Immune
Breathing
Urinary
Skin
Músculo-skeletal
Headaches
Mental health
Anything else not mentioned?
Please list any significant events in your life, which could have impacted your health.
Send
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?
Send
lisa@lisafabry.com