FEMALE TEEN 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: How often do you check your email: Home Phone: Work Phone: Mobile Phone: Current Weight: Weight Six Months Ago: Weight One Year Ago: Would you like your weight to be different? If so, how? Why did you sign up for a Health History? SOCIAL What is your relationship status? Do you have any pets? What grade are you in? Do you enjoy school? Please explain: Do you have a large or small group of friends? GENERAL HEALTH What are your main health concerns? Any other concerns Any serious illnesses, hospitalizations, or injuries? How is/was your mother’s health? How is/was your father’s health? What's your ancestry? How is your sleep? How many hours do you sleep per night? Do you wake up during the night? If so, why? Any pain, stiffness, or swelling? Any constipation, diarrhea, or gas? Any allergies or sensitivities? FEMALE TEEN HEALTH HISTORY Are your periods regular? How many days is your flow? How frequent? Are your periods painful or symptomatic? If so, please explain: Have you reached or are you approaching menopause? If so, please explain: What is your birth control history? Do you experience yeast infections or urinary tract infections? If so, please explain: MEDICAL List all supplements or medications: Do you take any supplements or medications? Are you involved with any healers, helpers, or therapies? What role do sports and exercise play in your life? FOOD Will your family and friends be supportive of your desire to make food and/or lifestyle changes? What percentage of your food is home-cooked? Do you enjoy the food? Where does your non-home-cooked food come from? Do you crave sugar, coffee, cigarettes, or drugs? Do you have any other major addictions? What foods did you eat often as a child? Breakfast Lunch Dinner Snacks Liquids What foods do you typically eat these days? Breakfast Lunch Dinner Snacks Liquids What the most important thing you should change about your diet to improve your health? ADDITIONAL COMMENTS Is there anything else you would like to share?