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© Copyright Endocrine Wellness, LLC Revised 09/05/2017
YOUTH HEALTH HISTORY QUESTIONNAIRE
Birth – 7 years
(To be completed by parent)
Child’s Name:_________________________________________ Date:__________________
Age ______ Date of Birth _____/______/______ Gender: Female Male
Height:_________ Weight:___________
Genetic Background: Please check appropriate box(es):
! African American
! Hispanic
! Mediterranean
! Asian
! Native American
! Caucasian
! Northern European
! Other
We would like to take the time to thank you for choosing our office to
assist you and your child on the journey to optimal health. Our ability
to draw effective conclusions about your child’s state of health and
how to optimize its improvement depends largely on the accuracy of
the information in which you provide, including symptoms that you
may consider minor. Health issues may be influenced by many
factors; therefore, it is important that you carefully consider the
questions asked in this form as well as those posed by the doctor
during your consultation.