Julian Christopher Cortez, M.Ed., M.A.
Holistic Health
Practitioner
Children's Health History Form
Full Name
Address
Zip
School Phone
Home Phone
Email
Age
Birthday
Place of Birth
Current Weight
Current Height
Current Grade
Favorite Subject
Favorite Color
Favorite Sport
Favorite Things to do with Friends?
Favorite Things to do when Alone?
What is You Bed Time
What is Your Wake-Up Time
Which Chores do you do Around the House?
Do You Wake Up at Night
Do you ever feel Sick, Tired or Grumpy?
What things do you like to do with Your Family?
Do you take vitamins or medications? Which Ones?
Do you have any Pets?
Do You Play a Sport or Excercise regularly?
Is your father Healthy?
Is your mother Healthy?
Have you been to the Hospital? What for?
The Yummy foods I like are?
breakfast
lunch
dinner
snacks
liquids
The Yucky foods I don't like are?
breakfast
lunch
dinner
snacks
liquids
What I want to Learn about my Body & Food is?
INTRO
:
HOME
:
PROGRAM
:
BIOGRAPHY
:
HEALTH HISTORY
:
CLASSES
:
TESTIMONIALS
:
PRODUCTS
:
RESOURCES
:
CONTACT
:
SITE MAP
Julian Christopher Cortez, M.Ed., M.A. | 6440 Palmetto Street - Ridgewood, NY 11385
