Youth Health History Form

All of your information will remain confidential.

Name:

Address:

Telephone:

Your email or parent's email:

Age:

Birthdate:

Place of Birth:

Height:

Weight:

Grade:

Why did you come for this health history?

Do you enjoy school? Please explain:

Do you have a large or small group of friends?

Who is your best friend?

What do you like about him or her?

What are some of your favorite movies and/or books?

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?

When is bedtime?

When do you wake up?

Do you ever wake up at night?

Do you ever have nightmares?

How would you rate your stress level? 1-10, low to high.

Enter a # from 1-10

What do you do to relax?

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?

Does anything else hurt?

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?

Anything else you want to say?