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CHILDREN HEALTH HISTORY FORM
All of your information will remain confidential between you and the Health Coach.
PERSONAL: First Name
SOCIAL
GENERAL HEALTH:
Do you ever wake up at night?
*
Yes
No
Sometimes
Never
Do you ever have nightmares?
*
Yes
No
Never
Sometimes
Do you get stomachaches?
*
Yes
No
Do you get headaches or earaches?
*
Yes
No
Is it hard to see or read?
*
Yes
No
Do you get itchy?
*
Yes
No
MEDICAL
FOOD
ADDITIONAL COMMENTS
Submit
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