Andrea Berez, MS, RDN Registered Dietitian Nutritionist 6 Auer Court, Suite D, East Brunswick NJ

Transcription

1 Background Information Andrea Berez, MS, RDN Registered Dietitian Nutritionist 6 Auer Court, Suite D, East Brunswick NJ aberezrd@njpedsrd.com Pediatric Patient Nutrition Assessment/Diet History Form Name: DOB: Gender: M/F Address: Phone: (Personal or Parent): General Health Information Primary Physician Name: Phone: Fax: Who Referred You/Your Child? Reason for Your Nutrition Visit: Past Medical History Please circle if you/your child EVER had or CURRENTLY have any of the following medical conditions: Celiac Disease Crohn s Disease Eating Disorder Eosinophilic Esophagitis Failure to Thrive Feeding Tube Food Allergies Food Intolerances Diabetes High Blood Pressure High Cholesterol High Trigylcerides Kidney Disease Underweight Overweight Obesity Growth Delay Polycystic Ovarian Syndrome Swallowing Disorder Irritable Bowel Syndrome Gastroesophageal Reflux Feeding Disorder Texture Aversion Autism Spectrum Disorder ADHD Obsessive Compulsive Disorder Feeding Tube Depression Anxiety Other: Have your ever been diagnosed or treated by a medical professional for eating disorders such as Anorexia, Bulemia, Binge eating disorder? Y/N if you answered yes, please explain: Surgery History Any Surgery? Y/N: If yes, please explain specific type of surgery and date:

2 Family History: Age Healthy/disease Overweight/Obese/Eating Issue? Mother: Father: Sisters: Brothers: Extended Relatives: Do you have a family history of the following? (Circle all that apply) High Blood Pressure High Cholesterol Diabetes Thyroid Disease Obesity Heart Disease Other: Is anyone in the household on a special diet? Y/N if yes, Explain: Nutrition Evaluation Are you currently on any medications? Please list: Do you/your child take any vitamins, supplements, herbs, etc? Please list: Describe your/your child sbowel movements (how many per say, consistency: pebble like, formed, loose, constipation, diarrhea) Weight and Height (Please bring growth records or charts with you to visit) Length/Height: (cm or in) Present Weight: lbs History of recent weight loss in past 6 months (Y/N); Intentional/Unintentional History of recent weight gain in past 6 months (Y/N); Intentional/Unintentional (If Applicable to your/your child s concerns): Desired Weight: In what time frame would you like to reach your desired weight? Highest Weight: lbs When? Lowest Weight: lbs When? If applicable, what is you main reason for your decision to lose weight or gain weight? If applicable, when did you begin gaining or losing excess weight (give reasons if known) :

3 Please list any previous diets you have been on, including dates/results of any weight loss: Please list who you/your child lives with. Please list who is involved in you/your child s daily lives, describe how he/she is related to your child. Do you/your child have dual households. If so, please describe the schedule. How often do you eat out? : Bring food in? : Types of foods eaten out/brought in? What restaurants do you eat at frequently? How often do you eat fast food? Who plans/cooks meals for you/your child? Who is responsible for food shopping? Please circle all that apply: Is food purchased at large supermarkets, specialty market, farmers market, convenience store, other? Do you read food labels? Y/N What specifically do you check for? Do you generally do things while eating? (examples: watch phone, tv, IPad/other ) Y/N Explain: Do you feel you need to distract your child with a screen to get he/she to eat? Y/N Explain: Food allergies/intolerances: Favorite Foods: Food Dislikes: Aversions to any specific textures or foods: Food cravings? Y/N Please indicate types of foods: Do you drink the following? (please circle all that apply and include ounces per day): Water oz Tea oz Coffee oz Decaf: oz Soda oz Diet soda oz Other: oz Do you use sugar/butter/margarine substitute?

4 Types: (If Applicable to your/your child s situation): What are your worst food habits? Best food habits? Snack Habits (Give examples of foods you frequently snack on, and when_: Please circle if you/your child has any of the following eating behaviors: Eat fast eat in bedroom sneak food eat large portions/multiple servings manipulative with food tantruming associated with food/meal times, etc. food seeking behaviors Restrictive food intake behaviors Physical Activity Information Please list any physical activities you participate in and how often you participate: If any, what other activities are you involved in? Please list your favorite hobbies, if any. How soon do you eat from the time you wake up? Describe: On a scale of 1 10, with 10 being the most hungry, how would you rate your hunger level before meals? What is your hungriest time of the day? Emergency Contact Information Name: Phone Number: Relationship: Primary Insurance Insurance Provider: Subscriber Name: DOB: Relationship to Patient: Employer: Social Security Number of the insured: Policy Number: Group ID/Plan Number:

5 Food Diary Please fill in the chart on the next page with you/your child s food/beverage intake on a typical weekday and weekend and be as accurate with your portion sizes as possible: i.e. cooked weight for all foods as cups for starch/grain/liquids, ounces for protein foods and beverages, slices for bread, etc., as well as common brands used. Weekday Food Diary Date: Breakfast: Food Time Place Lunch: Dinner: Weekend Food Diary Date: Breakfast: Food Time Place Lunch: Dinner:

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