Intake Form – RD Picky Eating

Date


Background

Child's name: Parents' names: Email:
Child’s Age: Gestational Age: Birth Weight:
Current Weight Height: Weight History (Recent loss or gain):


Supplements (vitamins/minerals/herbs) & Meds. Dosage & frequency:

Supplements & Meds Dosage Frequency
1
2
3


Has your child had any previous treatment for feeding or nutrition?


Child’s Health History: Do you have any of the following conditions?

Constipation Diarrhea Low Iron
Colds Eating Disorder Rashes/eczema
Recent Acute Illness Sleepiness Diabetes/BS issues
Poor weight gain Reflux


Allergies/Intolerances (please list):


Family doctor & Pediatrician name(s):


How would you describe your child’s appetite? Have there been changes lately?


Where does your child eat?


How does your child feed himself?


How do you encourage your child to eat (if you do so)?


If you are breastfeeding, how many times in 24 hours?


Does your child have food or texture dislikes?


Who shops and cooks in your house?


What is your child’s biggest eating challenges?


Instructions for Recording your Food and Fluid Intake

  1. Record your child’s food and fluid intake for three days. Please include TWO weekdays and ONE weekend day, if possible
  2. Record the time he/she consumed the food.
  3. Provide as much detail as possible: ex. what type of bread you use (white/whole grain), what type of milk you drink (skim, 2%), how the food was prepared (baked, fried, BBQ), condiments added and brand names.
  4. Record the approximate portions sizes (i.e. 8oz or 1 cup, 1 fist size, 1 deck of card-size, etc.)


Dietary Analysis Recording Form DAY ONE

Date


Attach your recording for Day 1 here:



Dietary Analysis Recording Form DAY TWO

Date


Attach your recording for Day 2 here:



Dietary Analysis Recording Form DAY THREE

Date


Attach your recording for Day 3 here:



PLEASE READ AND E-SIGN THE DOCUMENT BELOW

Waiver and Acknowledgement - RD

I grant permission for Jennifer House, RD to correspond with my (or my child’s) physician(s) and other necessary health care providers (i.e. Occupational Therapist, Dietitian) to obtain information relative to nutrition treatment. I acknowledge that any information provided to me by First Step Nutrition’s RD is designed to meet my personal dietary needs. It is NOT suitable for any other individuals and will not be transferred, copied or sold to another person.

In order to benefit from the treatment prescribed by Jennifer House, I realize that it is important for me to inform either my physician or Jennifer House of any changes I make in the application of my diet. It is my responsibility to report any side effects or problems immediately and to make the necessary adjustments to my treatment plan with my physician and or Jennifer House. I will not hold my physician or First Step Nutrition’s dietitian responsible for any complication that result from my failure to comply with either of the above.

I have agreed to have my Registered Dietitian keep records of our visits and to file these in a secure and appropriate place. I agree to have the Registered Dietitian contact other Health care Professionals to benefit in my care and to share my personal information. This may be accomplished by letter, phone, fax or email.

Cancellation Policy:

Twenty-four (24) hours notice is needed to cancel/reschedule your appointment. This allows our office to seek a replacement for the office time rented. If 24 hours notice is not provided, a fee of $25.00 will be charged to you.

Thank you for your cooperation and understanding.


Please sign below
By signing this form electronically, you are agreeing to the terms and conditions stated herein.