Pediatric Nutrition Assessment Form Page 2
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1
2Lifestyle Assessment
Activity
Do you have PE/Gym at school?
YES
NO
If yes, at what time?_________________
Do you get activity / play sports on a regular basis?
YES
NO
How much activity do you do per day?
None
1-30 min
30-60 min
60+ min
What type of activity / sports do you do?___________________________________________________
Are there any medical reasons that limit / stop (circle one) you from daily activity?
YES
NO Explain:_______________
How much time is spent each day sitting in front of a television or computer?
None
< 1 hr
1-2 hr
2+ hrs
Miscellaneous
Within the last year, how many days of school / work have you missed? ______________________________________
How would you rate your stress level?
Low
Moderate
High
During the past month, have you often been bothered by feeling down, depressed, or hopeless?
YES
NO
During the past month, have you often been bothered by little interest or pleasure in doing things?
YES
NO
What time do you wake up?___________
What time do you go to sleep?____________
Nap time(s)?__________________
Day Care?
YES
NO
Other caregivers:_________________________________________________________________
Nutrition Assessment
Height: ________ ft ________inches
Current Weight:_____________
Desired Weight:__________________
Lost Weight
Gained Weight
# lbs lost/gained:__________
No Change
In the past month have you:
Intentional
Unintentional
If you lost weight was it:
Do you have any diet restrictions? (include food allergies and intolerances) __________________________________________________
_________________________________________________________________________________________________________________
Give a sample of your meals for a typical day (If you brought in a food log, give it to the dietitian and go to the next question)
Time: ____________ Breakfast: ____________________________________________________________________________________
Time: ____________ Snack: ____________________________________________________________________________________
Time: ____________ Lunch: ____________________________________________________________________________________
Time: ____________ Snack: ____________________________________________________________________________________
Time: ____________ Dinner: ____________________________________________________________________________________
Time: ____________ Snack: ____________________________________________________________________________________
YES
NO
Is it hard to control what you eat?
How many times do you eat out (do not include any meals brought from home to school/work)?
0-1
2-4
5-8
Daily
Type of restaurants:
Fast food / Take out
Buffet
Cafeteria / Formal restaurant
Type of foods ordered when eating out: _________________________________________________________________________
No
Sometimes
Yes
If yes, how often? ______ times per week
Do you skip meals?
How often do you eat the following foods?
Fruit
daily/often
occasionally
rarely
never
Fruit Juice
daily/often
occasionally
rarely
never
Vegetables
daily/often
occasionally
rarely
never
Red Meat
daily/often
occasionally
rarely
never
Fish
daily/often
occasionally
rarely
never
Fried foods
daily/often
occasionally
rarely
never
Milk
daily/often
occasionally
rarely
never
Skim
1%
2%
Whole
Kind?
Soda
daily/often
occasionally
rarely
never
Regular
Diet
Kind?
0-1
2-4
5-8
9+
How many 8 oz glasses of water do you drink daily?
NO
YES
If yes, what type? __________
Amount ________ per day/week (circle one)
Do you drink alcohol?
NO
YES
If yes, what type? __________
Amount ________ per day/week (circle one)
Do you use tobacco?
Assessment reviewed by: _________________________________________________________RD Date: ________________________
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