212.227.8610
info@foodmattersnyc.com
Child Health History Form
First Name
Last Name
Address
Address Line 2
City
State
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
AE
AA
AP
Zip Code
Home Phone
Alternate Phone
Mobile Phone
Email
Age
Date of Birth
Place of Birth
Current Weight
Height
Favorite Activity
Favorite Sport
Current Grade
Favorite Color
Favorite Things to do with a Friend?
Favorite Things to do when Alone?
What is our Bed Time?
Do You Wake Up at Night?
No
Yes
What is our Wake Up Time?
Do You Ever Feel Sick, Tired, Grumpy?
No
Yes
What Things do You Like to Do with Your Family?
Health Concerns
Medications
Vitamins
Have You Ever Been Hospitalized? Is So, What For?
Is Your Mom Healthy?
No
Yes
Is Your Dad Healthy?
No
Yes
WHAT FOODS DID YOU EAT OFTEN AS A CHILD?
Monday
Tuesday
Wednesday
Thursday
Friday
Breakfast
Lunch
Dinner
Snacks
Liquids
FAVORITE FOODS/YUMMY FOODS?
Breakfast
Lunch
Dinner
Snacks
Liquids
FOODS I DON'T LIKE?
Breakfast
Lunch
Dinner
Snacks
Liquids
