Men’s Nutrition Form For Certified Nutrition Counselor, Brandy Hickman, CHHC, AADP, RYT Complete and submit this form before your initial consultation with Brandy Hickman. All of your information will remain confidential between you and Brandy.PERSONAL INFORMATIONName* First Last Email* How often do you check email?*Phone: Home:Phone: WorkPhone: Mobile*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?SOCIAL INFORMATIONRelationship status:*Where do you currently live?*Children:*Pets:*Occupation:*Hours of work per week:*HEALTH INFORMATIONPlease 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?*How is/was the health of your mother?*How is/was the health of your father?*What is your ancestry?*What blood type are you?*How is your sleep?*How many hours?*Do you wake up at night?*Why?*Any pain, stiffness, or swelling?*Constipation/Diarrhea/Gas?*Allergies or sensitivities? Please explain:*MEDICAL INFORMATIONDo 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 INFORMATIONWhat foods did you eat often as a child?*What are your breakfasts like these days?*What are your lunches like these days?*What are your dinners like these days?*What are your snacks like these days?*What are your liquids like these days?*Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?*Do you cook?*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 things I'm doing right now regarding my health are:*ADDITIONAL INFORMATIONWhat is a snapshot of your day, evening, and weekend?*Anything else you would like to share?