Female Teen Confidential Health History

Name & Contact
Name: 
Address: 
Email address: 
How often do you check email?: 
Telephone
Home: 
Cell: 
Personal Details
Age: 
 
Date of Birth: 
Place of Birth: 
Height: 
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?: 
Relationship status: 
What grade are you in? 
Do you enjoy school? Please explain: 
Do you have a large or small group of friends?: 
Health Details
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?: 
Do you sleep well?: 
How many hours?: 
Do you wake up at night?: 
Why?: 
Are your periods regular?: 
How many days is your flow?: 
How frequent?: 
Painful or symptomatic? Please explain: 
Birth control history: 
Do you experience yeast infections or urinary tract infections? Please explain: 
Are you concerned with body image? Please explain: 
 
Constipation/Diarrhea/Gas? Please explain: 
Allergies or sensitivities? 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 sports and exercise play in your life?: 
 
Diet Details
What foods did you eat often as a child?
Breakfast: 
Lunch: 
Dinner: 
Snacks: 
Liquids: 
 
What’s 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 food?: 
   
Where do you get the rest from?: 
Do you crave sugar, coffee, cigarettes, or have any major addictions?: 
The most important thing I should change about my diet to improve my health is: 
Anything else you want to share?: