Female Teen Health History

To be filled out by guardian if under the age of 18. Able to work directly with female teen (under the age of 18) with legal guardian verbal and written confirmation. Please request the sign off form in the “Additional Comments” section at time of submission.

Personal Information

Print your full name(required)

Email (required)

Home or Mobile Phone:(required)

Guardian's full name(required)

Guardian's Home Phone:

Guardian's Mobile Phone:(required)

Email Guardian's email(required)

How often do you check e-mail:

Age:(required)

Birthdate (month/date/year):(required)

Height:

Current weight:

Weight six months ago:

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

Pets?:

Place of Birth:

Why did you come for this health history? (required)

Social Information

Relationship status:

What grade are you in?:(required)

Do you enjoy school? Please explain:(required)

Do you have a large or small group of friends?:(required)

Who is your best friend?:

What do you do for fun?(required)

What is your favorite sport or activity?(required)

What are fun things you do with family?(required)

What are your favorite things to do when you are alone?(required)

What chores do you do around the house?(required)

Health Information

Please list your main health concerns:(required)

Other concerns and/or goals?:(required)

Any serious illnesses/hospitalizations/injuries?(required)

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?:(required)

How many hours?:(required)

Do you wake up at night?:(required)

Why?:

Any pain, stiffness or swelling?:(required)

Constipation/Diarrhea/Gas?:(required)

Allergies or sensitivities? Please explain:(required)

Female Teen Health

Are your periods regular?:(required)

How many days is your flow?:

How frequent?:

Painful or symptomatic? Please explain:

What is your birth control history?(required)

Do you experience yeast infections or urinary tract infections? Please explain:(required)

Medical Information

Are you concerned with body image? Please explain:

Do you take any supplements or medications? Please list:(required)

Do you have any healers, helpers, therapies, or pets? Please list:(required)

What role do sports and exercise play in your life?:(required)

Food Information – History

What foods did you eat often as a child?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

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

What percentage of your food is home-cooked?:(required)

Do you enjoy the food?: (required)

Where do you get the rest from?:(required)

Do you crave sugar, coffee, cigarettes, or drugs? Please explain: (required)

The most important thing I should do to improve my health is:(required)

Food Information – Present

What is your food like these days?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

Additional Comments

Anything else you would like to share?:

Print your name(required)

Print your name / Guardian(required)