Children’s Health History

Form adapted from the Institute for Integrative Nutrition.

Personal Information

Name

First Name

Last Name

Email or Parent's Email

Phone Number

(###)

###

####

Height

Weight

Social Information

Do you enjoy school? Please explain.

Do you have a large or small group of friends?

What do you do for fun?

What is your favorite sport or activity?

What are your favorite things to do alone?

What chores do you help with around the house?

Health Information

When is your bedtime?

Hour

Minute

Second

What time do you wake up?

Hour

Minute

Second

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 read or see?

Do you get itchy?

Medical Information

Do you have allergies or sensitivities? If yes, please describe.

Does anything else hurt?

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?

What do you want to learn about your body and about food?

Additional Information

Do you have anything else you would like to share?

Children's Health Form

Children’s Health History