Green Machine
H E A L T H
CSL
© 2018 Catherine Stewart-Lindley. All rights reserved.
Child's Health History
All of your information will remain confidential between you and the Health Coach.
First Name:
Last Name:
E-mail or parents email:
Home Phone:
Yours or Parent's Cell Phone:
Grade:
Age:
Date of Birth:
Place of Birth:
Height:
Weight:
Do you have pets?
Why did you come for this health history?:
Do you enjoy school? Please explain:
Do you have a large or small group of friends?
Who is your best friend?
What do you do for fun?
What is your favorite sport or activity?
What are fun things you do with family?
What are your favorite things to do when you are alone?
What chores you do around the house?
When is bedtime?
Do you ever wake up at night?
Does anything else hurt?
What do you eat for breakfast?
What do you eat for lunch?
What do you eat for dinner?
What do you eat for snacks?
What do you drink?
What foods do you wish you could eat more often?
What food do you wish you never had to eat again?
What do you want to learn about your body and about food?
Anything else you would like to say?
Do you get bellyaches?
Is it hard to see or read?
Do you have allergies or sensitivities?
When do you wake up?
Do you ever have nightmares?
Do you get headaches or earaches?
Do you get itchy?
Catherine Stewart-Lindley | Green Machine Health
greenmachinehealth@gmail.com | 917-699-8790
