Pediatric Nutrition Assessment Form
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2Name: ________________________________ Date of Birth: ___________
Email Address: ________________________________________________
Preferred method of contact:
Email
Phone: ____________________
PEDIATRIC Nutrition Assessment form
Patient/Parent signature:___________________________ Date:_________
General Information
Ethnicity:
Caucasian
African American
Hispanic
Native American
Asian
Middle Eastern
English
Other _______________________________
Language preference:
What school do you attend?_________________________________
Grade?___________________
Education:
Do you have a job?
YES
NO
Employment:
If yes, what do you do?_________________________________ What are your typical work hours?___________________
Learning Style: Are there any things we should know about that would interfere with your ability to learn?
None
Hearing
Visual
Reading
Language
Psychological
Other - __________________________
How do you learn best?
Reading
Doing
Observing/Listening
Classes
Films
Computer
Cultural / Religious Beliefs:
Do you have any cultural / religious practices or beliefs that influence your diet?
No
Yes If yes, please describe__________________________________________________________________________
Mothers name: ____________________________________
Father’s name: _______________________________________
Divorced parents: Who does the child spend most time with?
Mother
Father
Specify:______________________________
Medical History
Dad
Mom
Other
Dad
Mom
Other
Family medical issues:
Family medical issues:
Cancer
High blood pressure
Depression
High cholesterol
Diabetes
Gastrointestinal problems
Heart Attack / Stroke
Medical Diagnosis / Reason for this visit:______________________________________________________________________________
Dental – date of last exam: (month/year)_________________
Yes
No
List:____________________
Medication Allergies:
Hospitalizations: How many times have you been hospitalized? ____________________________
Reason(s)______________________________________________________________________________________________________
Emergency Room: How many times have you been to the ER? _____________________________
Reason(s)______________________________________________________________________________________________________
Prescription
Record the information as it is written on your medication containers
Medications:
Name
Dose
What is it for?
Start Date
Amount Taken
When Taken
(example)Singulair
4 mg
Asthma
3/5/03
1 tablet
At bedtime
Nonprescription
Medications:
Yes
No
Comment:
Yes
No
Comment:
Allergy meds
Laxatives
Cough/Cold meds
Diet pills
Aspirin/Pain relief
Vitamins/Mineral
Antacids
Other:
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