Children's Health History All of your information will be kept confidential between you and the Health CoachPERSONAL INFORMATION First Name *Last Name *Email or Parent's email *How often do you check your email? Parent's Home Phone Parent's Cell Phone Age Date of Birth Place of Birth Height Current Weight What grade are you in? Why did you come for a consultation? Social InformationDo you enjoy school? Please explain. Do you have a large or small group of friends? Who is your best friend? What is your favorite sports or activity? What do you do for fun? What are the fun things you do with your family? What are your favorite things to do when you are alone? What chores do you do around the house? Health InformationWhat time is bed time? What time do you wake up? Do you ever wake up at night? If yes, why do you wake up? Do you have nightmares? Do you get belly aches? Is it hard to see or read? Do you get itchy? Medical InformationDo you have allergies or sensitivities? Please explain. Are you on any prescription medications? Please list. Was your birth C-section or vaginal? Have you ever been hospitalized? Food/NutritionWhat do you eat for breakfast? What do you eat for lunch? What do you eat for dinner? What do you eat for snacks? What do you drink? What foods do you wish you could eat more often? What foods do you wish you never had to eat again? What do you want to learn about food and your body? Additional Comments Do you have anything else you would like to share? VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
