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?

    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?

    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

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