Children’s Health History

Personal Information

Please note that all of the information you provide in this form will remain confidential between you and the Health Coach.

Name: *

First

Last

Email or Parent's Email: *

Phone:

Age:

Height:

Birthdate:

Place of birth:

Current weight:

Grade:

Why did you come for this health history?

Social Information

Do you enjoy school? Please explain:

Do you have a large or small group of friends?

Who is your best friend?

What do you do for fun?

What is your favorite sport or activity?

What are fun things you do with family?

What are your favorite things to do when you are alone?

What chores do you do around the house?

Health Information

When is bedtime?

When do you wake up?

Do you ever wake up at night?

Do you ever have nightmares?

Do you get bellyaches?

Do you get headaches or earaches?

Is it hard to see or read?

Do you get itchy?

Do you have allergies or sensitivities?

Food Information

What do you eat for...

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

What foods do you wish you could eat more often?

What do you want to learn about your body and about food?

Additional Comments

Anything else you would like to share?

Children’s Health History