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Children's Health History
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First Name:
Your answer
Last Name:
Your answer
Email:
Your answer
How often do you check email?
Always
Often
Sometimes
Rarely
Never
Clear selection
Phone Number:
Your answer
Age:
Your answer
Height:
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Place of Birth:
Your answer
Current Weight:
Your answer
Weight six months ago:
Your answer
Weight one year ago:
Your answer
What grade is your child in?
Your answer
Does your child enjoy school? Please explain:
Your answer
Does your child have a large or small group of friends?
Yes
No
Clear selection
Please list your main health concerns in relation to your child:
Your answer
Other concerns?
Your answer
Any serious illnesses/hospitalizations/injuries?
Your answer
How is your health?
Your answer
How is/was the health of your child’s other parent?
Your answer
Where do your parents and grandparents come from?
Your answer
How is your child’s sleep?
Your answer
How many hours?
Your answer
Does he/she wake up at night?
Yes
No
Clear selection
Why?
Your answer
Constipation/Diarrhea/Gas? Please explain:
Your answer
Allergies or sensitivities? Please explain:
Your answer
Does your child take any supplements or medications? Please list:
Your answer
Does your child have any healers, helpers, therapies, or pets? Please list:
Your answer
What role does exercise, sports, and activities play in your child’s life?
Your answer
What food did your child eat often? (BREAKFAST)
Your answer
What food did your child eat often? (LUNCH)
Your answer
What food did your child eat often? (DINNER)
Your answer
What food did your child eat often? (SNACKS)
Your answer
What food did your child eat often? (LIQUIDS)
Your answer
What food does your child like these days? (BREAKFAST)
Your answer
What food does your child like these days? (LUNCH)
Your answer
What food does your child like these days? (DINNER)
Your answer
What food does your child like these days? (SNACKS)
Your answer
What food does your child like these days? (LIQUIDS)
Your answer
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Yes
No
Clear selection
What percentage of your food is home-cooked?
Your answer
Does your child enjoy the food?
Yes
No
Clear selection
Where do you get the rest?
Your answer
Does your child crave sugar, caffeine, etc.? Please explain.
Your answer
The most important thing I should do to improve my child’s health is:
Your answer
Anything else you would like to share?
Your answer
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