Male Teen Health History Form
All of your information will remain confidential between you and Health Coach Rivkie.
Personal Information
Name
First Name
Last Name
E-mail
How often do you check email?
Cell phone number
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Area Code
Phone Number
Age
Height
Birthdate
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Month
-
Day
Year
Date Picker Icon
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
Relationship status
What grade are you in?
Do you enjoy school? Please explain...
Do you have a large or small group of friends?
Health Information
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?
How is your sleep?
How many hours?
Do you wake up at night?
If yes, why?
Constipation, Diarrhea or Gas?
Allergies or sensitivities? Please explain...
Medical Information
Are you concerned with body image? Please explain...
Do you take any supplements or medications? Please list...
Do you have any healers, helpers, therapies or pets? Please list...
What role does exercise, sports and activities play in your life?
Food Information
What foods did you often eat as a child?
Include Breakfast, Lunch, Dinner, Snacks, Liquids
What is your food like these days?
Include 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?
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, or drugs? Please explain...
The most important thing I should do to improve my health is:
Additional Information
Anything else you would you like to share?
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