Begin Within Wellness | Complimentary Consultation

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Health Form for Children

PERSONAL INFORMATION

First Name:

Last Name:

Date of Birth:

Nationality:

Phone:

Your Email:

Height:

Weight:

School grade?

Why did you come for this health check?

HEALTH INFORMATION

When is your bedtime?

What time to you wake up in the morning?

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 snacks do you eat?

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

Anything else you would like to share?

Health Form for Teens

PERSONAL INFORMATION

First Name:

Last Name:

Date of Birth:

Nationality:

Phone:

Your Email:

how often do you check email?:

Height:

Weight:

Weight (1 year ago):

Would you like your weight to be different?

If so, what?

Why did you come for a health history?

HEALTH INFORMATION

What are your main health concerns?

Any other concerns you would like to share?

Any serious illnesses/hospitalizations/injuries?

How is/was the health of your mother?

How is/was the health of your father?

What do your parents and grandparents come from?

How is your sleep?

How many hours of sleep do you get?

Do you wake up at night often?

Do you have Constipation/Diarrhea/Gas?

Any Allergies or sensitivities?

MEDICAL INFORMATION

Are you concerned with body image? Please explain:

Do you take any medication and/or supplements?

Any healers, helpers, or therapies with which you are involved?

What role does sports and exercise play in your life?

DIETARY INFORMATION

What foods did you eat often as a child?

Breakfast	Lunch	Dinner	Snacks	Liquids

What foods do you eat these days?

Breakfast	Lunch	Dinner	Snacks	Liquids

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

Do you cook? What percentage of your food is home-cooked?

Where do you get the rest from?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

The most important thing I should change to improve my health is:

ADDITIONAL COMMENTS

Anything else you would like to share?

Health Form for Adults

PERSONAL INFORMATION

First Name:

Last Name:

Date of Birth:

Nationality:

Phone:

Your Email:

Height:

Weight:

Weight (1 year ago):

Would you like your weight to be different?

If so, what?

HEALTH INFORMATION

What are your main Health Concerns?

What are your current health related goals.

At what point in your life did you feel your best?

Any serious illnesses/hospitalizations/injuries?

How is/was the health of your mother?

How is/was the health of your father?

What is your ancestry?

What blood type are you?

How is your sleep?

How many hours of sleep do you get?

Do you wake up at night often?

Any pain, stiffness, or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities?

MEDICAL INFORMATION

Do you take any medication and/or supplements?

Any healers, helpers, or therapies with which you are involved?

What role does sports and exercise play in your life?

DIETARY INFORMATION

What foods did you eat often as a child?

Breakfast	Lunch	Dinner	Snacks	Liquids

What foods do you eat these days?

Breakfast	Lunch	Dinner	Snacks	Liquids

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

Do you cook? What percentage of your food is home-cooked?

Where do you get the rest from?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

The most important thing I should change about my diet to improve my health is:

ADDITIONAL COMMENTS

Anything else you would like to share?