Clients Name: Date:
Clients Gender: Clients Date of Birth/Age:
Do you have children besides the client(s)? If so, what are their names and ages?
What is your occupation/ what is your work schedule like? (days/week and hours/day)
What is your primary purpose for meeting with me? What struggles are you having with feeding your babies or older children?
Why is this important to you?
What do you hope to accomplish through our visits?
What support systems do you have? Why/How are these people support?
Please list/describe any current or past medical diagnoses or procedures for the client (children):
List any significant family medical/health history:
Do they take any vitamin/mineral or herbal supplements? If yes, please list names and dosage.
List any medications they are taking (prescription and/or over the counter):
When was their last pediatrician visit?
Has the child been diagnosed with any allergies, sensitivities, or intolerances thus far?
How often do they have a bowel movement?
Weight and Length Data
Height: Current weight (leave blank if unsure):
Has the child typically remained on their growth curve?
Clients Food and Eating History
For infants, is the baby breastfed, formula fed, or a combination?
For infants, have you started introducing solids yet? If so, purees or different consistencies?
What foods does your child like and dislike?
What particular struggles are you having with feeding the client?
Parents Food and Eating History
What was food like in your (the parents) house growing up?
Does anyone in your family have a history of dieting, disordered eating, or eating disorders?
Have you ever worked with a dietitian/nutritionist? If yes, tell me about your experience.
What is food like in your house now?
How many meals a day do you eat as a family?
Do you (the parent or caregiver) skip meals? If yes, which ones and why?
Where do you (the parent or caregiver) typically eat your meals?
Do you (the parent or caregiver) cook? Do you like to cook? Does someone else in your household do the cooking?
Who does the grocery shopping and cooking in your household?
Does your (the parent or caregiver) diet have a lot of variety or does it tend to be the same from day to day?
What foods do you (the parent or caregiver) love? What foods do you dislike?
If you have other children besides the client, what foods do they love? What foods do they dislike?