Initial Assessment Form – Pediatric Date Patient's Name Mailing Address Phone Parent's Email Address Parent's Occupation Gender MaleFemale Grade Level Emergency Contact Phone Pediatrician Physician's Name Physician's Address Physicians Phone Number Medical History Height Weight Recently Gained Weight? How Much? Recently Loss Weight? How Much? Are you currently being treated by a physician? If yes, please explain Past Medical History - Do you have a history of any medical conditions? Food AllergiesArthritisCancerEating DisordersHeart DiseaseShortness of BreathKidney DiseaseHigh Blood PressureOsteoporosisLiver DiseaseRenal DiseaseEndocrine Concerns (Diabetes, Hypoglycemia, Thyroid)Autoimmune Disease (Fibromyalgia, Rheumatoid Arthritis, Lupus)Gastrointestinal Concerns (Constipation, Diarrhea, Nausea, Vomiting, IBS, IBD, Celiac Disease)GERD (Heartburn, Reflux)High Blood Fats (Total Cholesterol, LDL, Triglyceride)Weight Concerns (Overweight, Underweight) Other Lab Results Date of last test Total Cholesterol LDL HDL TG Blood Pressure Blood Glucose HbA1c BUN Creatinine Other List current prescription and non-prescription medicines, vitamins, minerals and herbal supplements you’re taking. Nutrition What are your nutrition concerns or reasons for visit? General Nutrition/Eating Better/WellnessGastrointestinalHeart HealthSports NutritionVegetarianMeal PlanningWeight ManagementAnemiaDiabetesEating DisorderPicky Eater Other (specify) Have you seen a Dietitian before? Yes or No If yes, please explain when and why? How did you hear about Wonderfully Nutritious Solutions? Do you currently exercise? YesNo How many times per week? Types of Exercises (E.g. Weight training, cardio) For what length of time each day (minutes)? How long have you been on this exercise program? Do you have any condition that limits your physical activity? Yes or No. Explain Δ
