Children's Health History Form

Children's Confidential Health History Form

* Indicates required field

First name *

Last name *

Email (or your parents email) *

Phone Number *

Age *

Height *

Weight *

Grade *

Date of Birth (xx/xx/xxxx) *

Place of Birth *

Do you like 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 fun things do you do with your family? *

What are your favorite things to do when you're alone? *

What chores do you do around the house? *

When is your bedtime? *

Do you ever wake up at night? *

Do you get bellyaches? *

Is it hard to see or read? *

When do you wake up? *

Do you ever have nightmares? *

Do you get headaches or earaches? *

Do you get itchy? *

Does anything else hurt? *

What kinds of food do you eat?

Breakfast *

Snacks *

Lunch *

Drinks *

Dinner *

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? *

Anything else you want to share? *

Submit