Children's Health History

Personal Information

Please write or print clearly. All information listed will remain confidential between child, parent and Health Coach.

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* 1. First Name:

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* 2. Last Name:

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* 3. Phone:

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* 4. Email or parents’ email:

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* 5. Age:

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* 6. Date of Birth:

Date

Date

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* 7. Place of Birth:

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* 8. Height:

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* 9. Weight:

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* 10. Grade:

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* 11. Why did you come for this Health History?