Children's assessment form

Children's Registration and Nutrition Assessment Form

Either download and print registration/nutrition assessment form and bring to initial visit
OR fill out digital form below.

Patient Information

* Indicates required field

Child's Name *

First

Last

Parent's Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Main Phone Number *

Phone Number *

Fax Number *

Email *

D.O.B. *

Insurance Company *

Other insurance company *

Insurance Phone Number *

Does plan require a referral from your physician? *

Copay $ *

ID # *

Number of Visits Allowed by Insurance *

Has the deductible been met? *

Name of Primary Insured *

Referred by *

Physician *

Phone Number *

Fax Number *

Address of M.D. *

Line 1

Line 2

City

State

Zip Code

Country

Child Nutrition Assessment

Reason for nutrition consultation *

Medical History *

Describe your family health history. At what age did they develop disease? Where they obese? Did they smoke? *

Medications *

Herbs/Vitamins/Supplements *

Who takes care of child? *

Food allergies *

Does child experience *

constipation diarrhea

Exercise and sports: What does your child do? How often? *

Menstruating? Age of onset? *

Describe weight history *

What else affects appetite? *

What have you done to prevent weight gain? What obstacles do you see? *

How often do you eat out or order in? Types of restaurants? *

How much of the following are consumed per day?

Milk *

Ice cream *

Water/Seltzer *

Hard cheese *

Juice *

Yogurt *

Soda *

Favorite Foods *

Ethnic Culture *

Foods you particularly dislike? *

What vegetables do you eat regularly *

Fruits *

Please read the following information carefully. Clicking the "I agree" checkbox indicates your responsibility for this account and your guarantee of payment of all charges as they accrue. It is your responsibility to verify that your insurance plan covers your diagnosis for nutritional counseling.

I agree to reimburse you for office visits if insurance company doesn't pay.
I will pay for missed appointments unless I give 24 hours notice or it is a true emergency. Please note: insurance doesn't cover missed appointments. You will be responsible for paying my usual fee.
I authorize Kathy Levine to exchange records and information with my physician.

Click check box to agree to terms *

I agree

For office use only:

Height *

Weight *

BMI *

IBW *

ABW *

BMR *

Meal Plan *

TC *

LDL *

HDL *

CHOL/HDL *

BG *

HbA1C *

TG *

Thyroid *

TC *

LDL *

HDL *

CHOL/HDL *

BG *

HbA1C *

TG *

Thyroid *

TC *

LDL *

HDL *

CHOL/HDL *

BG *

HbA1C *

TG *

Thyroid *

TC *

LDL *

HDL *

CHOL/HDL *

BG *

HbA1C *

TG *

Thyroid *

TC *

LDL *

HDL *

CHOL/HDL *

BG *

HbA1C *

TG *

Thyroid *

Submit