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Diet and Health History Questionnaire (Children and Adolescents)
Diet and Health History Questionnaire (Children and Adolescents)
General Information:
Child's Name:
*
Today's Date:
*
Parent's/Care Giver's Name(s):
*
Address:
Phone:
*
Phone #2:
Email:
*
Age:
*
Date of Birth:
*
Gender:
*
Reason for Appointment:
*
Primary Care Provider:
Address/Phone:
Therapist:
Address/Phone:
Referred By:
Grade in School:
Name of School:
Parent's Marital Status:
Single
Married
Divorced
Separated
Widowed
Parent's Occupation(s):
Siblings: Brother(s):
Ages:
Sister(s):
Ages:
Medical History:
Height:
Current Weight:
Growth History:
Are you concerned with your child's weight?
Yes
No
Mother's Height:
Father's Height:
Are you concerned with your own weight?
Yes
No
Birth Weight:
Breast fed?
How long?
Bottle fed?
How long?
Formula:
Early feeding problems:
At what age were foods first introduced?
List complications:
Food allergies/intolerance as an infant/toddler?
Yes
No
Please specify:
Symptoms:
Normal Pregnancy?
Yes
No
List complications:
Normal Delivery?
Yes
No
List complications:
Normal Growth/Development?
Yes
No
List complications:
Please indicate whether your child or a family member have/had any of the following conditions:
Asthma
Cancer
Cardiovascular Disease
Diabetes
Drug Dependency
Eating Disorder
Food Allergies
Food Intolerances
Kidney Disease
Headaches
Heart Attack
High Cholesterol
Hypertension
Intestinal Problems
Menstrual Problems
Mental Health Issues
Obesity
Osteoporosis
Other:
Menstrual History (female patient):
Age began menstruating:
Have never menstruated
Dieting History:
Has your child ever dieted?
Yes
No
How many diets has your child been on?
Age of first diet:
Weight at that time:
Why did your child go on that diet?
Exercise History:
Does your child currently exercise/participate in sports?
Yes
No
Type, duration, frequency, and intensity of exercise activities:
What types of physical activities does your child enjoy?
Eating Habits:
How many days per week does your child eat:
Breakfast:
Lunch:
Dinner:
Snacks:
When does your child usually snack?
Does your child eat out (restaurants, take-out, fast food, etc.)?
Yes
No
How often?
List restaurants usually chosen:
Does your child take lunch to school or buy lunch at school?
Examples of food choices:
Does your child eat snacks at school?
Yes
No
What?
Who is responsible for grocery shopping?
Who prepares/cooks the meals?
Do you read food labels?
Yes
No
What do you look at on the label?
Does your child eat standing up, walking, etc.?
Yes
No
Does your child eat in the car, on the bus, etc.?
Yes
No
Does your child eat in front of the TV?
Yes
No
Does your child eat while reading, on the computer, etc.?
Yes
No
Does your child eat with others?
Yes
No
Does your child eat faster/slower than others?
Yes
No
Does your child eat when stressed/bored/lonely?
Yes
No
Does your child feel bad after eating?
Yes
No
Does your child sneak/hide food?
Yes
No
Does your child wish others wouldn't comment on what he/she ate?
Yes
No
Does your child feel like he/she eats differently than others?
Yes
No
Describe:
Does your child know what hunger & fullness feel like?
Yes
No
Does your child prepare his/her own meals?
Yes
No
Does your child avoid certain foods?
Yes
No
Please specify:
What are your child's favorite foods?
What foods does your child dislike?
Please list your main concerns about your child's nutritional intake:
Family Weight History:
Are any members of your family overweight?
Yes
No
Explain:
Are any members of your family underweight?
Yes
No
Explain:
Does anyone in your family diet?
Yes
No
Explain:
Did/Does anyone in your family have an eating disorder?
Yes
No
Explain:
Does your family eat meals together?
Yes
No
Which meals?
Submit
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