Please write or print clearly. All of your information will remain confidential between you and me. PERSONAL INFORMATION First Name: Last Name: Email: How often do you check email?: Phone Home: Work: Mobile: Age: Height: Birthdate: 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?: SOCIAL INFORMATION What is your relationship status?: What grade are you in?: Do you enjoy school? Please explain: Do you have a large or small group of friends?: HEALTH INFORMATION Please list your main health concerns: Other: Concerns?: 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?: How is your sleep?: How many hours?: Do you wake up at night?: Why?: Constipation/Diarrhea/Gas?: Allergies or sensitivities? Please explain: FEMALE TEEN HEALTH Are your periods regular?: How many days is your flow?: How frequent?: Painful or symptomatic? Please explain: What is your birth control history?: Do you experience yeast infections or urinary tract infections? Please explain: MEDICAL INFORMATION Are you concerned with body image? Please explain: Do you take any supplements or medications? Please list: Do you have any healers, helpers, therapies, or pets? Please list: What role does exercise, sports, and activities play in your life?: FOOD INFORMATION What foods did you eat often as a child? Breakfast: Lunch: Dinner: Snacks: Liquids: What is your food like these days? Breakfast: Lunch: Dinner: Snacks: 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 the food?: Where do you get the rest from?: Do you crave sugar, coffee, cigarettes, or drugs? Please explain?: The most important thing I should do to improve my health is: ADDITIONAL INFORMATION Anything else you would like to share?: