Children's Health History

Personal Information

Name

Address

Telephone

Email or parents' email

Age

Birthdate

Place of Birth

Height

Weight

Grade

Why did you come for this health history?

Social Information

Do you enjoy school? Please explain:

Do you have a large or small group of friends?

Who is your best friend?

What is your favourite sport or activity?

What are fun things to do with your family?

What are your favourite things to do when you are alone?

What chores do you do around the house?

Health Information

When is bedtime?

When do you wake up?

Do you ever wake up at night?

Do you ever have nightmares?

Do you get bellyaches?

Do you get headaches or earaches?

Is it hard to see or read?

Do you get itchy?

Do you have allergies or sensitivities?

Does anything else hurt?

Food Information

What do you eat for breakfast?

What do you eat for lunch?

What do you eat for dinner?

What do you eat for snacks?

What do you drink?

What foods do you wish you could eat more often?

What food 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 say?

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