Lindsay Stenovec, MS, RD
Family & Child Feeding Consultation Questionnaire
Parent Contact Information
Name
DOB
Home Phone
Cell Phone
Work Phone
Employer
Address
Occupation
Email
City
State
Sex
Smart Phone?
F
M
F
No
Fax
Zip Code
The best way to contact me is by (please circle all that apply):
Mail Email Home Phone Cell Phone Work Phone
I prefer that you contact me during:
AM PM Days: S M T W TR F S Hours:
Child’s Information (list all children if applicable)
Name
Yes
M
Fax
DOB
Sex
Grade in school:
Family Health History
Any history of chronic disease(s) and/ or condition(s)? Please circle or bold all that apply and
indicate family member in reference to child (i.e. grandparent, parent, aunt, sibling).
Type II Diabetes
Gestational Diabetes
Kidney Failure
High Cholesterol
Heart Disease
Gastrointestinal Disorder (IBD, IBS, Celiac, etc…)
High Blood Pressure
Other, please explain.
Child’s Health History
Any history of chronic disease(s) and/ or condition(s)? Please circle or bold all that apply.
Type II Diabetes
Date diagnosed:
Type I Diabetes
Date diagnosed:
Kidney Disorder
Date diagnosed:
Blood Pressure, Heart or
Cholesterol Disorder
Date diagnosed:
Other, please explain.
Digestive Disorder
Date diagnosed:
Feeding Disorder:
Date Diagnosed:
Child’s Weight History
Current Weight_____________ Stature for Age Percentile_________ Weight for Age Percentile________
BMI for Age Percentile _________ Weight for Stature Percentile _______
Please attempt to collect growth chart records from child’s physician.
Lindsay Stenovec, MS, RD
Family & Child Feeding Consultation Questionnaire
Has your child recently increased or decreased in weight? Have his or her growth chart percentiles
changed?
In your opinion, does your child display any eating habits that might be disordered?
Any history of eating disorders in your family?
Medications and Supplements
Please list all medications and dosage your child is currently taking:
1.
5.
2.
6.
3.
7.
4.
8.
Please list all supplements and dosage you child is currently taking: (this includes vitamins,
minerals, herbal supplements, etc…)
1.
5.
2.
6.
3.
7.
4.
8.
Parent’s Perception of Child’s Experience with Food & Exercise
Please list any surgeries or medical procedures that you feel may have affected your child’s diet,
lifestyle or ability to move:
1.
2.
3.
4.
Have you ever been advised by your physician to What special diet was it?
place your child on a special diet? Yes No
What was it like for you to provide the special diet?
Lindsay Stenovec, MS, RD
Family & Child Feeding Consultation Questionnaire
What was this like for your child to be on the special diet?
Does your child have any food allergies or intolerances? Yes No If yes, please specify.
Have you ever seen a dietitian or nutritionist for you or your child? If so, please describe your
experience.
What concerns do you have about your child’s weight, health, eating, and/or movement?
What concerns does your child have about his/her weight, health, eating, and/or movement?
Does your child know you are here today? If so, how has he/she responded to this?
How do you rate your child’s health?
How would you rate your child’s self esteem?
Excellent Good Fair Poor
Excellent Good Fair Poor
How confident is your child with eating?
How confident is your child with moving?
(Not Confident)1 2 3 4 5 (Very Confident)
(Not Confident)1 2 3 4 5 (Very Confident)
Please list other health practitioners your child is currently seeing i.e. pediatric physician, OB/GYN
(if relevant), therapist, psychiatrist, holistic health practitioner, physical therapist, speech therapist,
occupational therapist:
Lindsay Stenovec, MS, RD
Family & Child Feeding Consultation Questionnaire
Eating & Movement
What types of food does your child enjoy? Not enjoy?
What types of movement does your child enjoy?
What other activities does your child enjoy?
Lindsay Stenovec, MS, RD
Family & Child Feeding Consultation Questionnaire
Parent Lifestyle History and Assessment
Marital Status Single Married
Please list number of children and ages:
Any pregnancy complications?
# of Pregnancies ____________________
Please list any surgeries or medical procedures that have affected your diet or lifestyle:
1.
2.
3.
4.
Have you ever been advised by your physician to What special diet was it?
follow a special diet? Yes No
What changes were you able to make?
Have you ever seen a dietitian or nutritionist? If so, please describe your experience.
Please list other health practitioners you are currently seeing i.e. primary care, OB/GYN (if
relevant), therapist, psychiatrist, holistic health practitioner:
Lindsay Stenovec, MS, RD
Family & Child Feeding Consultation Questionnaire
Lifestyle History and Assessment
How do you rate your health?
Excellent Good Fair Poor
If applicable, how do you rate your family’s health?
Excellent Good Fair Poor
How confident are you in feeding yourself?
How Confident are you in feeding your family?
(Not Confident)1 2 3 4 5 (Very Confident) (Not Confident)1 2 3 4 5 (Very Confident)
Have you ever been on a diet? If yes, please list all.
1.
5.
2.
6.
3.
7.
4.
8.
Are you currently exercising? If yes, please specify.
Do you have any food allergies or intolerances? Yes No If yes, please specify.
Nutrition Consultation Expectations
What do you hope to accomplish with our visit?
What are your expectations?
How can I help you to meet your needs?
Thank you for taking the time to complete this questionnaire.
I look forward to meeting with you!