FAMILY TEEN HEALTH HISTORY
How often do you check email?
Phone Number Mobile:
Phone Number Home:
Date of Birth:
Place of Birth:
Weight 6 months ago:
Weight 1 year ago:
Would you like your weight to be different?
I don't care
If the answer to the above question was YES, what would you like your weight to be?
Living with Partner
What grade are you in?
Do you enjoy school? Please explain:
Describe your friend group (e.g. large, small):
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 & grandparent come from?
How is your sleep?
How many hours do you sleep at night on average?
Do you wake up at night?
A few times a night
If you do wake up at night, why?
Allergies or sensitivities? Please explain:
Female Teen Health
Are your periods regular?
Not at all
I don't get a period
How many days is your flow?
How frequent are your periods?
Are your periods painful or symptomatic? Please explain:
What forms of birth control have you used in the past?
Do you experience yeast infections or urinary tract infections? Please explain:
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?
What foods did you eat as a little kid?
What is your food intake like these days?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Do you cook?
What percentage of your food is home cooked?
Do you enjoy the food?
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I should do to improve my health is:
Anything else you would like to share?
Should be Empty: