Male Teen Confidential Health History

Please write or print clearly

Name:
Address:
Email address:
How often do you check email?

Telephone
Home:
Cell:

Age:
Height:
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?

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?

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?

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