Children’s Health History
Please print clearly!
Name: |
Address: |
Telephone: |
E-mail or parents email: |
Age: |
Birthday: |
Place of Birth: |
Height: |
Weight: |
Grade: |
Why did you come for this health history? |
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Do you enjoy school? Please explain: |
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Do you have a large or small group of friends? |
Who is your best friend? |
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What do you do for fun? |
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What is your favorite sport or activity? |
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What are fun things you do with family? |
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What are your favorite things to do when you are alone? |
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What chores you do around the house? |
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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? |
Do you have allergies or sensitivities? |
Does anything else hurt? |
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What do you eat for breakfast? |
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What do you eat for lunch? |
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What do you eat for dinner? |
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What do you eat for snacks? |
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What do you drink? |
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What foods do you wish you could eat more often? |
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What food do you wish you never had to eat again? |
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What do you want to learn about your body and about food? |
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Anything else you want to say?