Terms & Conditions
7 Day Detox
14 Day Flush
28 Day Reset
Children's Health History
E-mail or parents email:
Place of Birth:
Why did you come for this health history?
Do you have a large or small group of friends?
Who is your best friend?
What do you do for fun?
What are your favorite things to do when you are alone?
Do you enjoy school? Please explain:
What is your favorite sport or activity?
What are fun things you do with family?
What chores you do around the house? Please explain
When is bedtime?
Do you ever wake up at night?
Do you get bellyaches?
Is it hard to see or read?
Do you have allergies or sensitivities?
When do you wake up?
Do you ever have nightmares?
Do you get headaches or earaches?
Do you get itchy?
Does anything else hurt?
What do you eat for breakfast?
What do you eat for dinner?
What do you drink?
What food do you wish you never had to eat again?
Anything else you want to say?
What do you eat for lunch?
What do you eat for snacks?
What foods do you wish you could eat more often?
What do you want to learn about your body and about food?
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