Youth Health History - Easy Gluten Free Living

Contact
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone:*
Email or parent's email*
About You
What grade are you in?*
Do you like going to school? Tell me about it.*
Describe yourself. What are your special gifts or talents?*
Do you have lots of friends or a few?*
What is special about your best friend?*
What do you enjoy doing most?*
Which sports or physical activities do you participate in?*
What are fun things you do with family?*
How much time do you spend watching television? Playing on the computer?*
How do you help at home?*
Basic Health
Age*
Height*
Blood Type*
MM slash DD slash YYYY
Date of Birth*
MM slash DD slash YYYY
Where were you born?*
MM slash DD slash YYYY
How much do you weigh?*
Do you have allergies? If so, what are you allergic to? What happens?*
Please enter 'N/A' if not not applicable
How do you feel? Do you ever get headaches, stomach aches, ear aches or anything that makes you not feel good?*
Sleep Habits
What time is bedtime?*
What time do you wake up in the morning? Do you use an alarm?*
Do you ever wake up at night?*
- Yes
- No
Diet
How often do you go out to eat?*
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 is your favorite food?*
Additional
Anything else you'd like to share?

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