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Initial Consultation Form (Pediatric)
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* Indicates required question
Last Name
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Your answer
First Name
*
Your answer
Date of Birth
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Your answer
Gender
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Choose
Male
Female
Address
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Your answer
Phone Number (Home)
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Your answer
Phone Number (Cell/other)
*
Your answer
Email
*
Your answer
Food Allergies/ Intolerance/ Sensitivity
Your answer
Family history of food Allergies/ intolerance/ sensitivity
Your answer
Current Length/Height
*
In inches
Your answer
Length/Height History
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(At birth, 1st month, 2nd month, 3rd month, etc.)
Your answer
Current Weight
*
In pounds
Your answer
Weight History
*
(At birth, 1st month, 2nd month, 3rd month, etc.)
Your answer
Current Head Circumference
In cm or inches
Your answer
Current Head Circumference
(At birth, 1st month, 2nd month, 3rd month, etc.)
Your answer
Medical History
*
If no medical history, please enter "None".
Your answer
Family Medical History
*
If no family medical history, please enter "None".
Your answer
Medications/ Supplements
*
If no medications/supplements, please enter "None".
Your answer
I would like to see a dietitian because:
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Your answer
My health and nutrition-related goals are:
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Your answer
In the past, I have tried the following techniques, diets, behaviors, etc. to reach my nutrition goals
*
Your answer
Is your baby born prematurely?
*
Choose
Yes
No
Do you breastfeed or provide formula to your baby? If formula, indicate which formula.
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Your answer
How many feedings a day does your baby get?
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Your answer
How much your baby eats at each feeding? How many scoops (in grams or ounces)?
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Your answer
How often your baby urinates?
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Your answer
How many bowel movements your baby has each day, and their volume and consistency?
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Your answer
When did you or your child first experience a reaction to milk?
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Your answer
When did you or your child first experience a reaction to milk? Can you describe the reaction?
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Your answer
How soon after consuming milk or milk products do symptoms begin? How severe are the symptoms?
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Your answer
Does anything seem to improve the symptoms, such as allergy medication or milk avoidance?
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Your answer
What, if anything, appears to worsen the symptoms?
Your answer
Have your child tried any of the products made for infants with lactose intolerance? If yes, did those help?
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Your answer
Referring Clinician/ Primary Care Physician
Your answer
Contact of Referring Clinician/ Primary Care Physician
Your answer
Primary Insurance Carrier
Your answer
Insurance Number
Your answer
Insurance Group Number
Your answer
Name of Primary Card Holder
Your answer
Insurance Company Phone Number
Your answer
How did you find Simply Nutrition NYC or Registered Dietitian Katrin Lee?
Your answer
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