Diet and Health History Questionnaire (Children and Adolescents)

Diet and Health History Questionnaire (Children and Adolescents)

General Information:

Parent's Marital Status:

Medical History:

Are you concerned with your child's weight?
Are you concerned with your own weight?
Food allergies/intolerance as an infant/toddler?
Normal Pregnancy?
Normal Delivery?
Normal Growth/Development?

Please indicate whether your child or a family member have/had any of the following conditions:

Menstrual History (female patient):

Dieting History:

Has your child ever dieted?

Exercise History:

Does your child currently exercise/participate in sports?

Eating Habits:

How many days per week does your child eat:
Does your child eat out (restaurants, take-out, fast food, etc.)?
Does your child eat snacks at school?
Do you read food labels?
Does your child eat standing up, walking, etc.?
Does your child eat in the car, on the bus, etc.?
Does your child eat in front of the TV?
Does your child eat while reading, on the computer, etc.?
Does your child eat with others?
Does your child eat faster/slower than others?
Does your child eat when stressed/bored/lonely?
Does your child feel bad after eating?
Does your child sneak/hide food?
Does your child wish others wouldn't comment on what he/she ate?
Does your child feel like he/she eats differently than others?
Does your child know what hunger & fullness feel like?
Does your child prepare his/her own meals?
Does your child avoid certain foods?

Family Weight History:

Are any members of your family overweight?
Are any members of your family underweight?
Does anyone in your family diet?
Did/Does anyone in your family have an eating disorder?
Does your family eat meals together?
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