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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