Patient Name:

Nutirition Visit Intake 1-18 years old
Patient Name:
Date of Birth
Height
Weight
Parent/Caregiver Name
Concerns at today's visit
Recent weight gain or loss
Appetite:

GoodFairPoor
Food Allergies
Symptoms:

DiarrheaConstipationVomitingStomach Aches
Foods Avoided
Current Supplements
Current Medications
How many meals does your child eat each day
How many snacks?
Hours of screen time per day:
Water Intake:
On average, do you prepare food at home or buy from restaurants/take-out?
Exercise/Activities that your child enjoys:
Sleeping problems?
Hours of sleep/night