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CONFIDENTIAL

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

MEDICAL DISCLAIMER

The contents of this website are for informational purposes only and are not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Life Esteem Circle of Wellness

Children's Health History

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

I look forward to seeing you at our next session!

You have two options when completing the Health History. 1) Fill out the form below and press the "SUBMIT HEALTH HISTORY", OR 2) Download a copy of the Health History (download here), fill out form, and email it to info@lifeesteem.com

Date*

PERSONAL INFORMATION - First Name*

Last Name*

Email or parents’ email:*

Home Phone:*

Age

Birthdate

Place of Birth

Height

Weight

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 do you do for fun?

What is your favorite sport or activity?

What are fun things you do with family?

What are your favorite 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 wake up at night?

Do you ever have nightmares?

Do you get bellyaches?

A Do you get headaches or earaches?

Is it hard to see or read?

Do you get itchy?

MEDICAL INFORMATION - 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?

ADDITIONAL COMMENTS - Anything else you would like to share?

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