New Patient Intake Form - Pediatric (Ages 0-19)
1125 E Polston Ave, Suite APost Falls, ID 83854Phone: (208) 640-4502Fax: (208) 777-7330Email: admin@northernnutrition.netWeb: www.northernnutrition.net
General Information
Patient Full Name (Last, First & MI):
*
Last Name
First Name
Middle Initial
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Gender
*
Male
Female
Parent/Guardian (Last, First & MI):
*
Last Name
First Name
Middle Initial
Parent/Guardian Signature:
*
Today's Date:
*
-
Month
-
Day
Year
Date
Parent/Guardian Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred Method of Contact:
*
Call
Text
Email
Ethnicity:
*
Caucasian
Hispanic
Asian
African American
Other:
Mother's Name:
*
First Name
Last Name
Father's Name:
*
First Name
Last Name
Who is completing this intake paperwork?
*
Who does the patient live with? Please list family members & ages:
*
Would you be open to having a student or trainee sit in on your visit(s) with us as a teaching tool for them?
*
Yes
No
Is there anything we should know about that could interfere with the patient's ability to learn?:
*
None
Reading
Hearing
Language
Vision
Psychological
Other/Explain:
What grade level is the patient in?
*
Education:
Does the patient have a job?
*
Yes
No
If so, what does the patient do for work?
*
What are the patient's typical work days/hours?
*
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New Patient Intake Form - Pediatric (Ages 0-19)
1125 E Polston Ave, Suite APost Falls, ID 83854Phone: (208) 640-4502Fax: (208) 777-7330Email: admin@northernnutrition.netWeb: www.northernnutrition.net
Insurance & Billing
If we are billing insurance, please bring your insurance card(s) to your appointment. Not all insurance companies provide coverage for Medication Nutrition Therapy (MNT) or Nutrition Counseling. Please verify coverage with your provider. Note that patients are responsible for all non-covered charges, including co-pays, co-insurance, deductible, and/or non-covered services.
Primary Care Physician/Office:
*
Referring Provider:
*
How did you hear about Northern Nutrition?
Healthcare Provider
Insurance Website
Friend/Family
Other
Are you open to having a student or trainee sit in on your visit(s) with us as a teaching tool?
Yes
No
Primary Insurance Company:
*
Subscriber ID:
*
Group #:
*
Secondary Insurance Company:
Subscriber ID:
Group #:
Primary Reason for Visit:
*
(Please also list any specific goals the family, parents, and/or patient have).
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New Patient Intake Form - Pediatric (Ages 0-19)
1125 E Polston Ave, Suite APost Falls, ID 83854Phone: (208) 640-4502Fax: (208) 777-7330Email: admin@northernnutrition.netWeb: www.northernnutrition.net
Medical History
Rows
Self
Relative
Autism Spectrum Disorder
Anxiety
Depression
Irritable Bowel Syndrome
Constipation
Diarrhea
Heartburn
Bowel Resection
Swallowing/Chewing Difficulty
Diagnosed Eating Disorder
Celiac Disease
Osteoporosis
Prediabetes
Type 2 Diabetes
Type 1 Diabetes
High Blood Pressure
High Cholesterol
Cancer
Failure to Thrive
Other/Explain:
Medications/Supplements
Rows
Medication/Supplement
Dose
Reason for Taking
Start Date
1
2
3
4
5
6
7
8
9
10
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New Patient Intake Form - Pediatric (Ages 0-19)
1125 E Polston Ave, Suite APost Falls, ID 83854Phone: (208) 640-4502Fax: (208) 777-7330Email: admin@northernnutrition.netWeb: www.northernnutrition.net
Height (feet, inches):
*
Current Weight (lbs):
*
Desired Weight:
*
In the past month, has the patient:
*
Lost Weight
Gained Weight
No Change
If the patient lost weight, was it:
*
Intentional
Unintentional
Does the patient have any dietary restrictions? (include food allergies/intolerances)
*
Yes
No
Does the patient use a feeding tube?
*
Yes
No
If so, please answer the questions below:
Rows
Dates
Formula Name
Amount
Nasogastric (NG-tube)
Gastrostomy (G-tube)
Jejunostomy (J-tube)
Other:
Frequency of bowel movements: (times)
*
per Day
per Month
Consistency of bowel movements:
*
Hard
Loose
Floating
Soft
Watery
Pellets
On average, how much water does the patient drink per day?
*
Does the patient have a pacemaker in place?
*
Yes
No
How often does the patient go out to eat/get take-out? And where?
*
Does the patient skip meals?
*
No
Sometimes (If so, how often? x/wk)
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New Patient Intake Form - Pediatric (Ages 0-19)
1125 E Polston Ave, Suite APost Falls, ID 83854Phone: (208) 640-4502Fax: (208) 777-7330Email: admin@northernnutrition.netWeb: www.northernnutrition.net
Give a sample of your typical eating routine:
Time
Hour Minutes
AM
PM
AM/PM Option
Breakfast:
Time
Hour Minutes
AM
PM
AM/PM Option
Snack:
Time
Hour Minutes
AM
PM
AM/PM Option
Lunch:
Time
Hour Minutes
AM
PM
AM/PM Option
Snack:
Time
Hour Minutes
AM
PM
AM/PM Option
Dinner:
Time
Hour Minutes
AM
PM
AM/PM Option
Snack:
How often do you eat the following foods?
Rows
Daily/often
Occasionally
Never
Rarely
Fruit (ex. Apples, Bananas, Berries, etc.)
Vegetables (Potatoes, Broccoli, Salad, etc.)
Meat (Ex. Chicken, Fish, Steak, etc.)
Dairy (ex. Milk, Cheese, Yogurt, etc.)
Grains (ex. Bread, Rice, Oats, etc.)
Sugary Beverages (ex. Juice, Soda Pop, etc.)
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New Patient Intake Form - Pediatric (Ages 0-19)
1125 E Polston Ave, Suite APost Falls, ID 83854Phone: (208) 640-4502Fax: (208) 777-7330Email: admin@northernnutrition.netWeb: www.northernnutrition.net
Lifestyle Assessment
Does the patient have P.E./Gym class at school?
*
Yes
No
If so, how many days/wk?
Does the patient get activity/play sports on a regular basis?
*
Yes
No
If so, how many days/wk?
How much activity does the patient get?
*
1-30 min/day
30-60 min
60+ min
What type of activity/sport does the patient play?
Does the patient have any physical limitations to exercise?
*
Yes
No
If so, please explain what limits the patient's physical activity?
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