Kathy Levine MS, RD, CDN
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For New Clients
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
*
Choose one
Medicare
Oxford
Aetna
Cigna
Pomco
United Healthcare
Empire Blue Cross Blue Shield
Other insurance company
*
Insurance Phone Number
*
Does plan require a referral from your physician?
*
Choose one
Yes
No
Copay $
*
ID #
*
Number of Visits Allowed by Insurance
*
Has the deductible been met?
*
Choose one
Yes
No
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
*
Does child eat when:
*
Tired
Bored
Happy
Depressed
Stressed
Frustrated
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