Teen Female Health History Form

PERSONAL INFORMATION

Email

How often do you check email?

Age

Height

Weight

Would you like your weight to be different? If so, what?

Do you enjoy school? Please explain.

Why are you interested in bettering your lifestyle and nutrition?

SOCIAL INFORMATION

What is your relationship status?

What grade are you in?

Do you enjoy school? Please explain.

Do you have a small or large friend group?

HEALTH INFORMATION

Please list your main health concerns.

Any serious illnesses, hospitalizations, or injuries?

How is/was the health of your mother?

How is/was the health of your father?

Where does your family come from?

How is your sleep?

How many hours do you sleep?

Do you wake up at night? What wakes you up?

Do you have any constipation, diarrhea, or gas?

Allergies or sensitivities? Please explain.

FEMALE TEEN HEALTH

Are your periods regular?

How many does is your flow?

How frequent is your flow?

Painful or symptomatic? Please explain.

Do you experience yeast infections or urinary tract infections? Please explain.

MEDICAL INFORMATION

Do you take any supplements or medications? Please list.

What is your birth control history?

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?

What is your food like these days?

Will family and/or friends be supportive of your desire to make food and lifestyle changes?

What percentage of your food is cooked at home? Do you enjoy it?

Where do you get the other percentage 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 like to share?