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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

Female Teen 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 Address*

How often do you check email?

Home Phone:*

Work Phone:

Moble 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, 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?

Do you have any pets?

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?

Where do your parents and grandparents come from?

How is your sleep?

How many hours of sleep do you get?

Do you wake up at night?

Why do you think you wake up at night?

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:

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 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?

Do you crave sugar, coffee, cigarettes, or drugs? Please explain?

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

ADDITIONAL COMMENTS - Anything else you would like to share?

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