Sustainable | Healthy | Living - Female Teen's Health Form

Health History Forms

FEMALE TEEN'S Health History Form

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

How often do you check email?

Phone Home

Cell

Age

Height

Date of Birth

Place of Birth

Current Weight

Weight six months ago

One year ago

Would you like your weight to be different?

If so, what?

Why did you come for a health history?

Relationship status

What grade are you in?

Do you enjoy school? Please explain:

Do you have a small or large group of friends?

Please list your main health concerns

Other concerns and/or goals?

Any serious illnesses/hospitalizations/injuries?

How is/was the health of your mother?

How is/was the health of your father?

Where do your parents and grandparents come from?

Do you sleep well?

How many hours?

Do you wake up at night? If so, why?

Are your periods regular?

How many days is your flow?

How frequent?

Are they painful or symptomatic? Please explain:

What is your birth control history?

Do you experience yeast infections or urinary tract infections? Please explain:

Are you concerned with body image? Please explain:

Constipation/Diarrhea/Gas? Please explain:

Allergies or sensitivities? Please explain:

Do you take any supplements or medications? Please explain:

Any healers, helpers, or therapies with which you are involved? Please list:

What role does sports and exercise play in your life?

What foods did you eat often as a child?

For breakfast, lunch, dinner, snacks, and liquids.

What's your food like these days?

For breakfast, lunch, dinner, snacks, and liquids.

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

What percentage of your food is home cooked?

Do you enjoy food?

Where do you get the rest of your meals/food from?

What percentage of your foods are raw fruits/veggies/juices?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

How much water do you drink on average?

The most important thing I should change about my diet to improve my health is:

Anything else you want to share?