Children’s Health History

If you are a human and are seeing this field, please leave it blank.

All information listed will remain confidential between child, parent and health coach.

Personal Information

First Name

Last Name

Phone

Email or parents' email

Address

City/State/Zip

Age

Date of Birth

Place of Birth

Height

Weight

Grade

Social Information

If applicable, 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 on your free time?

What chores do you do around the house?

Health Information

What are your main health concerns/challenges?

When is bedtime?

When do you wake up?

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

Allergies or sensitivities?

Delivery: Vaginal or C-section?

Breastfed or Formula?

Antibiotic or Drug use History?

Vaccine History?

Food 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?

Additional Information

Do you have anything else you would like to share?