Pediatric Nutrition Intake · R.E.S.T.O.R.E. MNT

PHI-minimized form

This clinical intake collects the minimum information needed for nutrition care. Your child’s full name, contact details, and address are collected separately on the Business Intake and consent forms and are not repeated here. This allows your clinical record to be used in secure automated systems that don’t need your full identity.

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Section 1

Who Is Completing This Form?

This form is being completed by: *

Client (self)

Parent / Guardian

Both together

Caregiver

N/A

Name(s) of person(s) completing this form:

Relationship to client (if not the client):

Primary Reason for Visit

What brings you to nutrition therapy? *

Please provide as much detail as you're comfortable sharing. This helps us understand the full picture from the very start.

Client initials:

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Section 2

About the Client

First Name *

Last Initial *

Preferred Name (if different)

Birth Month & Year *

Type in whatever format feels easiest, e.g., “March 2015” or “3/2015”. We only need month and year, not the day.

Age *

Height (inches)

Gender Identity *

Female

Male

FTM / Trans Male

MTF / Trans Female

Genderqueer

Choose not to disclose

Other

N/A

School / Occupation Status

Select all that apply: *

✓

In school (K–12)

✓

Homeschooled

✓

College / University

✓

Employed

✓

Unemployed

✓

Other

Please describe what the client does day-to-day:

Grade level, program, sport/activity, part-time job, or anything else that fills most of their week.

If employed or volunteering — what kind of work?

Household Structure

Select all that apply: *

✓

Live with parent(s)

✓

Live with spouse / partner

✓

Independent / living alone

✓

Children in household

✓

Other living situation

If parents are divorced or separated — is the eating structure the same in both homes?

Yes

Sometimes

N/A — not divorced

N/A

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Section 3

Current Care Team

We only contact providers you authorize. Collaboration between your team leads to better outcomes.

🧠 Therapist / Counselor / Psychologist

Allow contact?

Name

Practice

Phone

Fax

Reason seeing

How long have you worked with this provider?

< 3 mo

3–6 mo

6–12 mo

1–2 yr

3+ yr

🩺 Primary Care / Pediatrician

Allow contact?

Name

Practice

Phone

Fax

How long have you been a patient?

< 1 yr

1–3 yr

4–10 yr

10+ yr

💊 Psychiatrist / Prescriber / APRN

Allow contact?

Name

Practice

Phone

Fax

How long working with this provider?

< 3 mo

3–6 mo

6–12 mo

1–2 yr

3+ yr

➕ Other Provider

Allow contact?

Provider Type

Name

Practice

Phone

Fax

Reason seeing

Use this to add additional providers — e.g., a second specialist, school nurse, sports medicine, occupational/physical therapist, or anyone not already listed above.

Provider Diagnoses (Medical, Psychiatric, Nutritional) — include dates if known:

Records you would like us to obtain for care coordination:

Authorization to Collaborate with Care Team

By signing below, I authorize Sinnergy Wellness Group to communicate with the providers I have enabled above. This may include sharing session notes, nutrition assessments, and clinical updates. This authorization may be revoked at any time in writing.

Signature (type full name)

Date

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Section 4

Records & Growth Data

Available Records

Please select all records available to share:

✓

Recent bloodwork (past 30 days)

✓

Bloodwork (past 60 days)

✓

Bone density / DEXA scan

✓

Weight history / anthropometrics

✓

EKG / ECG

✓

Vitals record

✓

Treatment center records

✓

PCP note from last visit

✓

Special testing (specify below)

✓

Growth curve data (from pediatrician)

Date of last bloodwork

Next scheduled bloodwork

Date of last vitals

Next scheduled vitals

Growth Curve Trends

Growth curve pattern (select all that apply):

✓

Stable — following their curve consistently

✓

Crossing down 1 percentile curve

✓

Crossing down 2+ percentile curves

✓

Crossing upward

✓

Fluctuating

✓

Growth curve data not available at this time

✓

I can request from our pediatrician and have them sent over

Percentile Data (from most recent growth chart)

Height-for-Age

percentile

Weight-for-Age

percentile

BMI-for-Age

percentile

EKG, Echo, or DEXA — include dates and results if available:

📎 Upload Health Records & Growth Charts

Upload any available records before the first session. This significantly reduces time spent gathering information during the initial evaluation.

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Click to upload or drag files here

Growth curves · Blood work · Labs · PCP notes · EKG/DEXA results · PDF, JPG, PNG · Max 20MB

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Section 5

Medical & Health History

Hospitalizations & Surgeries

Hospitalizations (reason and date) — or N/A:

Surgical history (procedure and date) — or N/A:

Emergency room or urgent care visits (related to current issue, with dates) — or N/A:

Current & Past Medical Diagnoses

Tap Y (yes), N (no), or N/A for each. Tapping Y will open a detail field.

Family Medical History

Same conditions — for immediate family members. Tap Y to add detail.

Additional family history notes:

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Section 6

Developmental History

Developmental history — growth, milestones, and childhood health:

Include any notable milestones (walking, talking), early childhood illnesses, NICU stay, developmental delays, or concerns your provider has mentioned.

Onset & Course

Describe what's been going on with eating, health, or body recently: *

"Can you walk us through what's been happening and how it started?"

Changes noticed since symptoms began:

What feels most important for us to talk about? *

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Section 7

Reproductive & Hormonal Health

This section applies to clients of all genders. Please skip any questions that don't apply and note N/A. Your responses are completely confidential.

For each item, tap Y, N, or N/A. Tapping Y opens a detail field for notes.

Additional hormonal, reproductive, or endocrine notes:

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Section 8

Medications & Supplements

Prescription medications: *

Name, dose, frequency, and reason. Put N/A if none.

Over-the-counter medications:

Include antacids, laxatives, sleep aids, allergy meds, pain relievers — with frequency.

Nutrition supplements, vitamins, minerals, powders, bars, or protein shakes:

Include brand, dose, and frequency.

Dairy & Protein Preferences

Dairy type preference:

Whole milk

2% milk

1% / Skim

Lactose-free

Fairlife

Almond milk

Oat milk

Soy milk

No dairy

N/A

Protein / meat preference:

Chicken / poultry

Beef

Pork

Fish / seafood

Eggs

Vegetarian

Vegan

Pescatarian

N/A

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Section 9

Nutrition History

Appetite issues, changes, or concerns:

Chewing or swallowing difficulties:

GI concerns (bloating, gas, reflux, nausea, constipation, diarrhea, pain, etc.):

Food allergies, intolerances, or sensitivities (food, medication, environmental):

Food Preferences & Avoidances

Food preferences — foods you enjoy or would like included:

Food dislikes — strong dislikes (these will be avoided in your plan):

Concerns about choking, swallowing, or other oral/texture issues:

Examples: difficulty swallowing certain textures, history of choking episodes, gagging on specific foods, sensory concerns with food consistency, post-swallow-study recommendations, etc.

Foods currently avoided and why:

Meal Context

Who prepares meals, how often, and where?

Who do you usually eat with?

Alone

Family

Friends

Partner

It varies

N/A

How are meals typically served?

Family-style (serve yourself)

Pre-plated by someone else

Pre-portioned containers

I plate my own food

Varies

N/A

School or work lunch (packed, purchased, or skipped):

Packed from home

Purchased at school / work

Usually skip

Mix of these

N/A

Grocery shopping — who shops, where, how often:

Cooking skills and confidence:

I don't cook

Beginner

Some basics

Comfortable

Confident / experienced

N/A

Frequency of eating out, restaurants, takeout, or delivery:

Rarely (< 1×/week)

1–2×/week

3×/week

4–5×/week

Almost daily

Typical restaurants or food sources:

Portion understanding — do you feel confident with serving sizes?

Yes, very confident

Somewhat

No, not sure

I intentionally avoid thinking about it

N/A

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Section 10

Appetite, Tolerance & Hunger Cues

Select Good, Fair, or Poor for each:

Overall appetite

Ability to recognize hunger cues

Ability to recognize satisfaction cues

Ability to recognize fullness cues

Tolerance of current diet overall

Details or comments on any of the above:

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Section 10

Exercise, Sports & Activity

Include all intentional exercise, sports, teams, and movement that is part of daily life.

Additional notes on activity, movement, or physical limitations:

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Section 12

Weight History & Perception

Please complete each row with as much detail as you're comfortable sharing — weight, age, timeframe, feelings about the change, and context all help us understand your history.

Weight MetricDetails / Notes

Current Weight

What is the most recent recorded weight and date?

Usual Body Weight (UBW)

What has been their typical weight for most of their life — and for how long?

Highest Lifetime Weight (HBW)

What is the highest weight ever recorded? Age and circumstances?

Lowest Lifetime Weight (LBW)

What is the lowest weight ever recorded? Age and circumstances?

Desired / Goal Weight (DBW)

What weight do they feel they should be or want to be? Why?

Recent Weight Changes

Any changes recently? Amount, timeframe, intentional or not? Feelings about it?

Weighing Practices

How are they typically weighed? Preferred style?

At home (daily)

At home (occasionally)

At doctor's office only

Smart scale / MyClearStep

Avoids being weighed

Treatment facility only

Blind (not told the number)

Open (sees number)

Prefers to avoid weighing entirely

No preference

N/A

Weight Fluctuations

Does weight tend to stay stable or fluctuate? Pattern?

Weight Perception

How do they currently see/feel about their weight? Comparison to others? Impact on mood or functioning?

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Section 13

Goals of Nutrition Therapy

What feels most important for us to talk about first?

Is there anything specific you want us to know before our first session?