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Children’s Health History

All of your information will be held confidential between child, parent and Health Coach.

Personal Information

First Name
Last Name
Email or Parent's Email *
How often do you check your email?
Age
Date of Birth
Place of Birth
Height
Weight
Grade
Why did you come for a health history?

Health Information

When time is bed time?
What time do you wake up?
Do you ever wake up at night?
Do you have nightmares?
Do you get belly aches?
Do you get headaches or hearaches?
Is it hard to see or read?
Do you get itchy?

Medical Information

Do you have allergies or sensitivities?
Does anything else hurt?
Were you born vaginal delivery or C-Section?
Have you ever been hospitalized?
Are you on any prescription medications? If yes, please list.

Nutrition 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 foods do you wish you never had to eat again?
What do you want to learn about food and your body?

Additional Information

Do you have anything else you would like to share?

Verification

Please enter any two digits *Example: 12
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