How often do you check email?
Date of Birth
Place of Birth
Weight Six Months Ago
Weight One Year Ago
Why Did You Come for a Health History?
What Grade is Your Child In?
Does your child enjoy school?
Does your child have a large or small group of friends? Please explain.
Please list your main health concerns in relation to your child:
Any serious illnesses/hospitalizations/injuries?
How is your health?
How was/is the health of your child's other parent?
Where do your parents & grandparents come from?
How is your child's sleep?
How many hours?
Does he/she wake up at night?
Constipation/Diarrhea/Gas? Please explain:
Allergies or sensitivities? Please explain.
Does your child take any supplements or medications? Please explain.
Does your child have any healers, helpers, therapies, or pets? Please list.
What role does exercise, sports, and activities play in your child's life?
What foods does your child eat often?
What percentage of your food is home cooked?
Does your child enjoy the food?
Where do you get the rest?
Does your child crave sugar, caffeine, etc.? Please explain.
The most important thing I should do to improve my child's health is:
Anything else you would like to share?
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