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? |
|
|
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 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? |
|
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?
