Female Teen Confidential Health History

Please write or print clearly

Email address:
How often do you check email?


Date of Birth:
Place of Birth:

Current weight:
Weight six months ago:
One year ago:

Would you like your weight to be different?  Yes No
If so, what?

Why did you come for a health history?

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?

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?

What is your ancestry?

What blood type are you?

Do you sleep well?
How many hours?

Do you wake up at night?

Any pain, stiffness or swelling?

Are your periods regular?
How many days is your flow?
How frequent?

Painful or symptomatic? Please explain:

What is your birth control history?:

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:

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

What role does sports and exercise play in your life?

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 cook?

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?

Pin It on Pinterest

Share This