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Children's Confidential Health History Form
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Indicates required field
First name
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Last name
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Email (or your parents email)
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Phone Number
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Age
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Height
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Weight
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Grade
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Date of Birth (xx/xx/xxxx)
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Place of Birth
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Do you like school? Please explain.
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Do you have a large or small group of friends?
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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 fun things do you do with your family?
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What are your favorite things to do when you're alone?
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What chores do you do around the house?
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When is your bedtime?
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Do you ever wake up at night?
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Do you get bellyaches?
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Is it hard to see or read?
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When do you wake up?
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Do you ever have nightmares?
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Do you get headaches or earaches?
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Do you get itchy?
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Does anything else hurt?
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What kinds of food do you eat?
Breakfast
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Snacks
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Lunch
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Drinks
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Dinner
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What foods do you wish you could eat more often?
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What foods 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 share?
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Submit
Home
About Me
Reishi Mushroom Tincture
Bach Flower Essenses
Ionic Foot Detox Bath
Ionic Foot Detox Consent Form
Slate Creations
Hand Sanitizer
My Approach
Contact Me