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First Name:
Last Name:
Date of Birth:
Nationality:
Phone:
Your Email:
Height:
Weight:
School grade?
Why did you come for this health check?
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 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 your bedtime?
What time to you wake up in the morning?
Do you ever wake up at night? ---A lotSometimesEvery once in a whileAlmost never
Do you ever have nightmares? ---A lotSometimesEvery once in a whileAlmost never
Do you get bellyaches? ---A lotSometimesEvery once in a whileAlmost never
Do you get headaches or earaches? ---A lotSometimesEvery once in a whileAlmost never
Is it hard to see or read? ---YesNoSometimes
Do you get itchy? ---YesNoSometimes
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 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?
Anything else you would like to share?
how often do you check email?: ---Very OftenOftenSometimesNot OftenAlmost Never
Weight (1 year ago):
Would you like your weight to be different? ---YesNo
If so, what?
Why did you come for a health history?
Relationship Status: ---SingleIn a relationshipMarriedI'd rather not say
What grade are you in?:
Do you enjoy School?:
Please explain why you like/dislike school:
Do you have a large group of friends?:
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? ---Very OftenOftenSometimesNot OftenAlmost Never
Do you have Constipation/Diarrhea/Gas?
Any Allergies or sensitivities?
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?
What foods did you eat often as a child?
What foods do you eat these days?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? YesNo
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:
Children: ---012345+I'd rather not say
Pets:
Occupation:
Hours of work per week:
Where do you live:
What are your main Health Concerns?
What are your current health related goals.
At what point in your life did you feel your best?
What is your ancestry?
What blood type are you? ---Not sureO+O-A+A-B+B-AB+AB-
Any pain, stiffness, or swelling?
Constipation/Diarrhea/Gas?
Allergies or sensitivities?
The most important thing I should change about my diet to improve my health is:
