CHILDREN’S HEALTH HISTORY Please write or print clearly. Your information will remain confidential between you and your Health Coach PERSONAL First name: Last name: Age: Height: Date Of Birth: Place of Birth: Email(or parents's email): Phone: Weight: Grade: Why did you sign up for a Health History? SOCIAL 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's your favorite sport or activity? What are 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? GENERAL HEALTH When is your bedtime? When do you wake up Do you ever wake up at night? Do you ever have nightmares? Do you get stomachaches? Do you get headaches or earaches? Is it hard to see or read? Do you get itchy? MEDICAL Do you have allergies or sensitivities? Does anything else hurt? FOOD 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 foods do you wish you never had to eat again? What do you want to learn about your body and about food? ADDITIONAL COMMENTS Is there anything else you would like to share?
