Nutrition Outpatient Diet History Form

Child's Name: ______

Caregiver’s Name: ______Relationship to Child: ______

Please answer the following questions about your child's dietary habits. Only answer those questions that apply.

  1. What are your concerns about your baby’s/child’s nutrition? ______

______

  1. Does your child have any chronic illness or medical condition? YESNO If yes, please list: ______
  2. Was your baby/child premature? YESNOIf yes, how many weeks? ______
  3. Has your baby/child seen a registered dietitian before? YES NO If yes, where? ______
  4. Does your baby/child have any food allergies? YESNO If yes, please list: ______
  5. What reaction does your child have when these foods are eaten? ______

How would you categorize it? mild moderate severe life threatening

  1. Was your child ever on a special diet? YES NO If yes, who recommended the diet? ______
  2. Are there any food practices related to cultural/ethnic/religious beliefs? YESNO
  3. Does your baby/child drink: (indicate by a checkmark all that apply and estimate amount per 24 hours)

breastmilk______whole cow’s milk ______

infant formula ______2% milk ______

Pediasure or similar product______skim milk ______

Instant breakfast ______goat’s milk ______

water______soft drinks ______tea ______juice ______

other: ______

  1. Was your baby/child ever breastfed? YES NO
  2. If you are currently breastfeeding, do you have any concerns? If yes, please specify:______

______

  1. If your baby/child is on formula, list all formulas used: ______
  2. If your baby/child is on formula, how is it prepared? Are other supplements added?

follow directions on cancereal sodium

add more water than directions call forpolycose potassium

add less water than directions call foroil/microlipid other______

  1. If your baby/child is on formula, is the formula iron fortified? YES NO If no, why not? ______
  2. If your baby/child is on formula, how many cans of formula do you use each week?

_____ powdered_____ liquid concentrate_____ ready to feed liquid

  1. Is your child enrolled on the WIC Program? YES NO If yes, where? ______

If yes, do you ever have to buy formula?YES  NO If yes, how many cans each month? ____

  1. Does your baby/child take vitamin or mineral supplements?

vitamins ADC multivitamin with minerals iron fluoride herbal products other______

  1. Does your baby/child take a bottle to bed? YES NO If yes, what is in the bottle? ______
  2. Do you add solid foods to the bottle? YES NO
  3. Sleep/wake cycle: (circle hours when your baby/child is usually awake)

12mid 1 2 3 4 5 6 7 8 9 10 11 12noon 1 2 3 4 5 6 7 8 9 10 11

  1. At what times does your baby/child eat?

12mid 1 2 3 4 5 6 7 8 9 10 11 12noon 1 2 3 4 5 6 7 8 9 10 11

  1. Does your child eat at approximately the same time every day? YES NO
  2. In what position is your baby/child during feedings?  lap/cradles in arms infant seat walker

laying flat on back high chair regular chair other: ______

  1. How does your baby/child eat? (circle all that apply)

breast bottlespout cupopen cupspoonfork infant feeder fingers straw special feeding equipment feeding tube

  1. How does your baby/child act during the feeding? happy/eager concentrates on eating fussy

easily distracted tires easily sleepy/tired trouble breathing while eating must be burped frequently frequently gags/coughs/chokes

  1. Do any of the following apply to your child at his/her present age? (check all that apply)

7mo of age or older and has not started using a cup yet

9 mo of age or older and does not finger feed yet

12 mo of age or older and drinks liquids primarily from the bottle

19 mo of age or older and does not use a spoon yet

  1. If your child is older than 12 mo of age, does he/she avoid or reject any of the following food groups? (mark all that apply) grains (cereal, bread, rice, pasta) fruits vegetables dairy (milk, cheese, yogurt) protein sources (meat, eggs, dried beans and peas) fats (butter, salad dressings, oils)
  2. Does your baby/child prefer foods at a certain temperature? YES NO
  3. Does your baby/child regularly eat: (check all that apply)

Strained/pureed/baby foods: cerealjuicefruitvegetable meatdinners egg yolk

Table foods:cereal breadpastajuicefruitvegetablesmeat poultry fish beans/peas peanut butter cheese

  1. How often does your baby/child eat? Every ____ hours; _____ times per day; _____ meals; _____ snacks
  2. How long does it take your baby/child to finish a meal? < 30 minutes 30-45 minutes  >45 minutes
  3. At what age did you begin solid foods? ______. What was the first food? ______
  4. Describe your child’s appetite: goodfairpoor
  5. How do you know your baby/child is hungry? (check all that apply) awakens sucks on hand/fingers fussy cries screams says words that mean food points
  1. How do you know your baby/child is full? (check all that apply) stops eating falls asleep

spits out food or nipple turns away from food plays with food or is easily distracted

  1. Does your baby/child do anything that upsets you at mealtimes such as refusing to eat, excessive throwing of food or utensils or other? Please explain: ______
  2. What describes your baby’s/child’s usual feeding behavior?

seems to enjoy eating, takes feedings easily, good appetite

happy at beginning of feeding, then often gets fussy or distressed during feedings

frequently has trouble breathing while eating

often does not wake for feeding, tires easily with feedings, or often has difficulty finishing feedings

eats slowly, usually takes more than 30 minutes (infants)/45 minutes (toddler) to eat (excludingtime for diaper changes, play, etc.)

usually has difficulty sucking, swallowing or chewing

frequently gags, coughs, or chokes during feedings

refuses to eat, is difficult to feed, fussy throughout most of feeding, arches backward,or doesn’t seem to enjoy eating

picky eater, seems to eat very little, not interested in food or eating, or has poor appetite

  1. Does your baby/child experience any of the following?difficulty with sucking difficulty with swallowing

difficulty with chewing spit up or vomiting gagging diarrhea constipation

  1. Usual stool frequency:______
  2. Does your baby/child take any medicines other than vitamin or mineral supplements? YES NO

If yes, please list: ______

  1. How many meals does your child skip?

 5-10 meals per week Less than 5 meals per week 1-2 meals per week None

  1. What meal(s) does your child usually skip? ______
  2. What are some of your child’s favorite foods? ______
  3. Does your child eat clay, paint chips, or anything not usually considered food? YES NO

If yes, what? ______How often? ______

  1. Where does your child eat most of their meals?  high chair  kitchen table living room

on the run in front of the TV school/daycare other:______

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