PEDIATRIC NUTRITION QUESTIONNAIRE

Please allow 30-45 minutes to complete this questionnaire and answer the questions as thoroughly as possible so that we may make the best possible nutritional assessment. Your answers to personal questions are important as they provide helpful context for establishing a productive partnership. That said, please answer only the questions you are comfortable answering.

BASIC INFORMATION

Child's name (First)

Last:

Address:

City:

State:

Zip:

Birth Length & weight:

Gender:

Age:

Date of birth:

Grade:

Current Height & Weight:

With whom (persons or animals) do you share your home

Parent/Guardian Name:

Home Phone:

Cell Phone:

Work Phone:

Email:

Contact Preference:

MEDICAL INFORMATION

Family Medical History

If other, specify:

Client Medical History

Has your child been diagnosed with any medical conditions?

Yes No

If yes, indicate medical diagnosis.

Client Birth History:

Term

Premature

Vaginal delivery

Cesarian delivery

Pregnancy complications?

Pre-eclampsia

Gestational diabetes

Toxemia

Other

If other, specify:

Birth or newborn complications?

Breathing problems

Jaundice

Birth Defect

Trouble feeding

Other

If other, specify:

Breastfed

Bottle-Fed

Any medications or supplements used during pregnancy?

Alcohol

Pre-Natal Vitamin

Folic Acid

Prescription medication

Smoking

Other

If other, specify:

What are your primary concerns for seeking nutrition support:

Please list any food allergies, restrictions, or sensitives and your child's reaction:

Has your child ever had a major chemical exposure?

Yes No

If so, when and to what?

Where and when have you lived or traveled outside of the U.S. and Canada?

Do you follow a modified immunization schedule?

Is there anything that surfaced during a recent medical test, lab work, or doctor's visit that tou would like to report?

CURRENT MEDICATIONS (Over-the-Counter and Prescription)

Add Medications

Has your child had prolonged use of antibiotics, steroids, or NSAIDs (please indicate which medication)

CURRENT DIETARY OR HERBAL SUPPLEMENTS

Add Current dietary or Herbal supplements

How's your child's dental health?

How many bowel movements does your child have per day?

Does your child suffer from constipation or diarrhea?

How often does your child urinate per day?

NUTRITION

Does your child follow a specific diet?

Yes No

How many meals are cosumed daily?

How many glasses (8 ounces) water is consumed daily?

Does your child consume soda, juice or sports drinks?

Yes No

If yes, indicate type and frequency.

Your child's top 3 favorite foods:

How many meals are eaten away from home each week?

0-1 2-3 4-5 5+

The most important thing that could be changed about my child's diet to improve health is:

Additional information you wish to share about your child's eating patterns, preferences

LIFESTYLE

How many hours does your child sleep?

Does your child have difficulty falling asleep?

Yes No

# of times your child awakens during the night & reasons for waking?

How much time does your child spend playing outdoors?

What extracurricular activities is your child involved in?

How many hours of TV/video/computer time does your child have per day?

What are your child's interests/passions?

REVIEW OF BODY SYSTEMS

Please place an "X" next to anything your child is currently experiencing. Issues that your child has, mark with a "P"

Head:

Eyes/Ears/Nose:

Neck & Throat:

Allergies & Immune System:

Female Reproductive:

Date of last menses:

Urinary:

Neuropsychiatric:

Gastrointestinal:

Skin:

Musculoskeletal:

Respiratory:

MOODS YOUR CHILD EXPERIENCES FREQUENTLY

SIGNIFICANT LIFE EVENT

Please list major events and the dates they occurred. Include illnesses, medical conditions, births, deaths, marriages, divorces, accidents, moves, job changes, and anything else you feel greatly impacted your child's life.

Add new row

MSQ - MEDICAL SYMPTOMS/TOXICITY QUESTIONNAIRE

The Toxicity and Symptom Screening Questionnaire identifies symptoms that help to identify the underlying causes of illness, and helps you track your progress over time. Rate each of the following symptoms based upon your health for the past 30 days. If you are taking this for a repeat visit, record your symptoms for the past 48 hours ONLY.

Point Scale:

0 = Never or almost never have these symptoms | 1 = Occasionally have it, effect is not severe |

2 = Occasionally have it, effect is severe | 3 = Frequently have it, effect is not severe | 4 = Frequently have it, effect is severe.

DIGESTIVE TRACT

Nausea or vomiting

Diarrhea

Constipation

Bloated feeling

Belching or passing gas

Heartburn

Intestinal/Stomach pain

TOTAL

EARS

Itchy ears Total

Earaches, ear infections

Drainage from ear

Ringing in ears, hearing loss

TOTAL

EMOTIONS

Mood swings

Anxiety, fear or nervousness

Anger, irritability, or aggressiveness

Depression

TOTAL

ENERGY/ACTIVITY

Fatigue, Sluggishness

Apathy, Lethargy

Hyperactivity

Restlessness

TOTAL

EYES

Watery/itchy eyes

Swollen, reddened or sticky eyelids

Bags or dark circles under eyes

Blurred or tunnel vision (not near or farsightedness)

TOTAL

HEAD

Headaches

Faintness

Dizziness

Insomnia

TOTAL

HEART

Irregular or skipped heartbeat

Rapid or pounding heartbeat

Chest pain

TOTAL

JOINT/MUSCLES

Pain or aches in joints

Arthritis

Stiffness or limitation of movement

Pain or aches in muscles

Feeling of weakness or tiredness

TOTAL

LUNGS

Chest congestion

Asthma, bronchitis

Shortness of breath

Difficulty breathing

TOTAL

MIND

Poor memory

Confusion, poor comprehension

Poor concentration

Poor physical coordination

Difficulty in making decisions

Stuttering or stammering

Slurred speech

Learning disabilities

TOTAL

NOSE

Stuffy Nose

Sinus problems

Hay fever

Sneezing attacks

Excessive mucus formation

TOTAL

SKIN

Acne

Hives, rashes or dry skin

Hair loss

Flushing or hot flashes

Excessive sweating

TOTAL

WEIGHT

Binge eating/drinking

Craving certain foods

Excessive weight

Compulsive eating

Water retention

Underweight

TOTAL

OTHER

Frequent illness

Frequent or urgent urination

Genital itch or discharge

TOTAL

GRAND TOTAL

KEY TO QUESTIONNAIRE

Add individual scores for each group. Add each group scores to get a grand total.

Optimal is less than 10. | Mild Toxicity: 10-5- | Moderate Toxicity: 50-100 | Severe Toxicity: over 100

Your information will be encrypted.