Request edit access
Female Teen Health History
Welcome to It's All Food, Health & Fitness Coaching with Tracey. Please take a few minutes to complete this form. All submitted information is strictly confidential. Thank you!
PERSONAL INFORMATION
First and Last Name *
Your answer
Nickname *
Your answer
Email *
Your answer
How often do you check your email? *
Phone (Home & Mobile) *
Your answer
Age *
Your answer
Height and Weight *
Your answer
Birthdate/Place of Birth *
Your answer
Current Weight *
Your answer
Desired Weight *
Your answer
Lowest Weight *
Your answer
Highest Weight *
Your answer
Why did you choose to come for a health consult? *
Your answer
SOCIAL INFORMATION
What is your relationship status? *
Your answer
What grade are you in? *
Your answer
Do you enjoy school? Please explain: *
Your answer
Do you have a large or small group of friends *
Your answer
What do you enjoy doing? Do you have any hobbies? *
Your answer
HEALTH INFORMATION
Please list and/or describe your main health concerns? *
Your answer
Other concerns: *
Your answer
Any serious illnesses/hospitalizations/injuries? If so, include dates. *
Your answer
How is/was the health of your mother? *
Your answer
How is/was the health of your father? *
Your answer
What do your parents and grandparents come from? *
Your answer
How is your sleep? *
Your answer
How many hours do you sleep? *
Your answer
Do you wake up at night? If so, why? *
Your answer
Constipation?Diarrhea/Gas? Please explain: *
Your answer
Allergies or sensitivities? Please explain: *
Your answer
TEEN HEALTH
At what age did you get you first period? *
Your answer
Are your periods regular? *
Your answer
How many days is your period? *
Your answer
When was your last period? *
Your answer
What is your birth control history? *
Your answer
Do you experience yeast infections or urinary tract infections? Please explain: *
Your answer
How is your energy level? *
Rate your daily stress level: *
MEDICAL INFORMATION
Are you concerned with your body image? Please explain: *
Your answer
Do you take supplements or medications? Please list: *
Your answer
Do you have any healers, helpers, therapists or pets? Please list: *
Your answer
What role does exercise, sports, and physical activities play in your life? *
Your answer
What foods did you eat often as a child? Include beverages also. *
Your answer
What are your food and beverages like these days? *
Your answer
What percentage of your food is home-cooked? Where do you get the rest of your food? *
Your answer
Do you enjoy food? *
Your answer
Do you crave any of the following: sugar, salt, coffee, pasta, bread, candy, sour, chocolate, meat, soda, fats, spicy, cigarettes, alcohol, or drugs? Please explain: *
Your answer
Do you overeat? If so, which foods and how often? *
Your answer
Have you ever had to follow dietary restrictions? If so, how did you do with those restrictions? *
Your answer
The most important thing I could do now to improve me health is: *
Your answer
Will your family/friends be supportive of your decision to make healthy food and lifestyle changes? *
ADDITIONAL INFORMATION
Is there anything else you would like to share? *
Your answer
ACKNOWLEDGEMENT
By placing my initials below, I acknowledge that any dietary, supplemental or lifestyle suggestions made by Tracey D. Abdul-Wahhab, CHC, CGFT are entirely recommendations and are not intended as the diagnosis, cure or treatment for any disease or ailment. I also acknowledge that my physician is my primary health care provider and is responsible for supervising all changes that I make in my diet, exercise and nutrient intake. If potential client is a minor, guardian's initials are required also.
INITIAL and DATE *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service