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Child's Intake Form
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Child Name
*
Mr
Ms
Master
Email
Age
*
Parent / Guardian Name
*
Mrs
Mr
Ms
Baby
Master
Prof
Dr
Gen
Rep
Sen
St
Parent / Guardian Email
*
Height
*
Weight
*
Does the child feel healthy at this weight?
Yes
No
Others
Describe the child's weight history. Any fluctuations? Any past diets--successful or not?
Has the child previously made any nutritional changes? When, what and why and per whose recommendations?
Grade in school?
Please list child's sports or extracurricular activities.
Please rate the child's stress level.
Low
Average
High
Very High
Please list child's primary causes of stress.
Please list child's stress relief mechanisms.
Please list any accidents or traumatic events in the last 10 years.
Static Content
Below, please list child's physical activity, duration and intensity.
Physical Activity
Duration
Intensity
- Select Value -
Value 1
Value 2
Value 3
Please list any other movement throughout the day.
Average hours of sleep per night.
Difficulty falling asleep?
- Select Value -
Never
Occasionally
Most of the time
Always
Wakefulness at night?
- Select Value -
Never
Occasionally
Most of the time
Always
Please share any other lifestyle related issues here.
Are meals taken on a regular schedule most days?
How often does the family cook at home?
- Select Value -
All meals
2 meals a day
1 meal a day
a few meals a week
once a week
once a month
never
Others
Who plans, shops for and cooks the meals?
How many meals are eaten out per week?
What are the client's 5 favorite foods?
What are the child's least favorite foods?
Please describe a favorite restaurant and meal out.
Please list the 5 healthiest foods in the child's diet.
Please list the 5 least healthy foods in the child's diet.
How many 8-oz. glasses of water does the child drink in a day?
How often are meals consumed in front of the TV?
Please list any bad habits around food.
How often does the child eat the below foods?
Fruit
Daily
2-4 times a week
Once a week
Once a month
Never
Vegetables
Daily
2-4 times a week
Once a week
Once a month
Never
Tofu - Tempeh - Miso
Daily
2-4 times a week
Once a week
Once a month
Never
Other Soy
Daily
2-4 times a week
Once a week
Once a month
Never
Nuts & Seeds
Daily
2-4 times a week
Once a week
Once a month
Never
Nut Butters
Daily
2-4 times a week
Once a week
Once a month
Never
Peanuts & Peanut Butter
Daily
2-4 times a week
Once a week
Once a month
Never
Beans & Legumes
Daily
2-4 times a week
Once a week
Once a month
Never
Whole Grains
Daily
2-4 times a week
Once a week
Once a month
Never
Dairy Products
Daily
2-4 times a week
Once a week
Once a month
Never
Fish
Daily
2-4 times a week
Once a week
Once a month
Never
Red Meat
Daily
2-4 times a week
Once a week
Once a month
Never
Poultry
Daily
2-4 times a week
Once a week
Once a month
Never
Eggs
Daily
2-4 times a week
Once a week
Once a month
Never
Margarine & Vegetable Oil
Daily
2-4 times a week
Once a week
Once a month
Never
Butter
Daily
2-4 times a week
Once a week
Once a month
Never
Olive Oil
Daily
2-4 times a week
Once a week
Once a month
Never
Snack & Junk Food
Daily
2-4 times a week
Once a week
Once a month
Never
Fast Food
Daily
2-4 times a week
Once a week
Once a month
Never
Snack & Junk Food
Daily
2-4 times a week
Once a week
Once a month
Never
White Bread
Daily
2-4 times a week
Once a week
Once a month
Never
Fried Foods
Daily
2-4 times a week
Once a week
Once a month
Never
Dessert
Daily
2-4 times a week
Once a week
Once a month
Never
Candy
Daily
2-4 times a week
Once a week
Once a month
Never
Soda
Daily
2-4 times a week
Once a week
Once a month
Never
Diet Soda
Daily
2-4 times a week
Once a week
Once a month
Never
Sports Drinks
Daily
2-4 times a week
Once a week
Once a month
Never
Alcohol
Daily
2-4 times a week
Once a week
Once a month
Never
Coffee
Daily
2-4 times a week
Once a week
Once a month
Never
Tea
Daily
2-4 times a week
Once a week
Once a month
Never
How often is the child gassy/bloated after a meal?
How often is the child have heartburn or reflux?
How soon after eating does the child feel hungry again?
How many bowel movements does the child have per day or week?
How often does the child have constipation of hard stool?
How often does the child have diarrhea?
Current or Previous Conditions
Diabetes Type 1
Diabetes Type 2
Allergies (please elaborate on the right)
Chronic Fatigue
Eczema
Anemia
PMS/Menstrual Irregularity
Thyroid Disorder (please elaborate on the right)
Migraines
Asthma
Celiac Disease
Hypoglycemia/Low Blood Sugar
Chronic Constipation
Blood Clotting Problems
Colitis
Eating Disorders (please elaborate on the right)
Food Sensitivities (please elaborate on the right)
Do you frequently experience any of the following?
Diarrhea
Constipation
Bloating/Gas
Heartburn/Reflux
Nausea
Colds/Flu
Sinus Problems
Headaches
Hay Fever
Mood Swings
Attention/Focus Problems
Bleeding Gums
Easy Bruising
Brittle Nails
Dry Skin/Lops
Vomiting (with nausea)
Hives/Rashes
Dental Cavities
Chemical Sensitivities
Acne/Boils
Muscle Cramps
Joint Pain/Stiffness
Memory Problems
Infections (please elaborate on the right)
Please list the child Environmental Allergies:
Please describe Thyroid Disorder:
Please describe Eating Disorder:
Please list Food Sensitivities:
Please list types of infections experienced:
Please list known medical conditions:
Please list significant illnesses in infancy or childhood:
Please list frequency of the child's antibiotic use in the last 5 years:
Please list the child's current prescription medications:
Please list the child's current vitamins and supplements:
Please describe any health (physical or emotional) symptoms that currently affect the child. How long have they been a problem?
Please add any other comments here:
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