Female Teen Health Form

All of your information will remain confidential between you and your Health Coach.

Date:

Personal Information

First Name * :

Last Name * :

Email * :

How often do you check email?:

Home Phone:

Work Phone:

Mobile Phone:

Age:

Height:

Birthdate:

Place of birth:

Current weight:

Weight six months ago:

Weight one year ago:

Would you like your weight to be different?:

If so, how?:

Why did you sign up for a Heath History?:

Social Information

Relationship status:

Where do you currently live?:

Pets:

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 and/or goals?:

Any serious illnesses/hospitalizations/injuries?:

How is/was the health of your mother?:

How is/was the health of your father?:

What is your ancestry?:

What blood type are you?:

How is your sleep?:

How many hours?:

Do you wake up at night?:

Why?:

Any pain, stiffness or swelling?:

Constipation/Diarrhea/Gas?:

Allergies or sensitivities? Please explain:

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:

Medical Information

Are you concerned with body image? Please explain:

Do you take any supplements or medications? Please list:

Any healers, helpers or therapies with which you are involved? Please list:

What role do sports and exercise play in your life?:

Food Information

What foods did you eat as a child?

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 does your non-home-cooked food come from?:

Do you crave sugar, coffee, cigarettes, or have any major addictions?:

The most important thing I should do to improve my health is:

What is your food like these days?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

Additional Comments

Anything else you would like to share?:

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Print your name (guardian or parent if client under 18 years of age)

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Female Teen Health History