Children’s Health History

    Please write or print clearly. All information listed will remain confidential between child, parent and Health Coach.

    PERSONAL INFORMATION

    First Name:

    Last Name:

    Phone:

    Email or parents’ email:

    Age:

    Birthdate:

    Place of Birth:

    Height:

    weight:

    Grade:

    Why did you come for a 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?

    MEDICAL INFORMATION

    Do you have allergies or sensitivities?

    Does anything else hurt?

    FOOD INFORMATION

    What 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 food do you wish you never had to eat again?

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

    ADDITIONAL COMMENTS

    Do you have anything else you would like to share?