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Patient Diet History Form (All Ages)

PLEASE NOTE:
This form must be filled out completely. If a question does not apply, please mark "No" and/or fill in the field with "N/A". All questions are important for our office to better serve our patients.

Email Address:


Phone Number:


Child's Name:


Form Filled Out By:


Date Filled Out:


Has he/she lost or gained weight?
Lost   Gained

Please describe:


Is he/she a picky eater?
Yes   No

How many ounces of water does he/she eat everyday?   

Does he/she have any adversion to food?
Yes   No
If yes, please describe:


Please describe if abdominal pain is associated with eating foods, and what food:


If yes, how long after eating does the abdominal pain occur?


Please describe if vomitting is associated with eating foods, and what foods:


Please describe if he/she has difficulty swallowing when eating:


Does he/she have a preference for milk or meat products?
Yes   No
If yes, please describe:


Does your child eat fruits and vegetables everyday?
Yes   No
Please explain your answer:


Describe your child's dietary intake of "junk food":


What is his/her activity level?
Active   Sedative

Please explain your answer:


Does he/she have excessive flatulence?
Yes   No
Please explain your answer:


How many ounces of milk does he/she drink in a day, please describe?


How many ounces of formula does he/she drink in a day, please describe?


What is the brand of the formula referenced above?


How is he/she being fed?
Orally    Nasogastric Feeding Tube    PEG    G-J Tube   

What is his/her mode of feeding?
Continuous    Bolus

For continuous feeding, he/she gets how many cc per hour?


For bolus feeding, he/she gets how many cc over a minute?


His/her total caloric intake in a day is:


He/she was breastfed until when (if never breastfed mark "never"):


Weaning from being breastfed/formula fed, started when?


When solid foods were introduced, were they tolerated well?
Yes   No
Please describe your answer:


Please mark if there was a history of the list below (mark all that apply):
Rash    Vomitting    Blood in Stool   

After solid foods were started, what is the consistency of stools for him/her the majority of the time?
Soft    Firm    Hard    Loose   

Thank you for taking the time to fill out this form, we do appreciate your efforts. Your child's health is important to us, your answers will help us serve your child's needs better.