Nutritional Intake Form

Prior to your first nutrition consultation, please complete this form at least 1-2 days prior to your scheduled appointment.

First and last name of person completing form

Phone

Address

About the patient

Child's first and last name

Primary reason for referral

Has the child seen a dietitian in the past?

Yes

Child's age

Child's current height

Child's current weight

Current medications (please include all prescriptions, vitamins, over-the-counter medications, and herbal or alternative remedies):

Allergies:

Medical history (surgeries, medical problems, diagnoses, procedures, hospitalizations):

Does your child use a feeding tube?

Yes

Please provide a detailed log of the child’s food and beverage intake over the past three days, including the type and quantity of each item consumed, as well as the time of day each intake occurred.