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Home
About
Specialties
Our Team
- Dietitians
  - Kristine Sinner, MS, RDN/LDN, CEDS-C
  - Diana Douglas, MS
- Therapists
  - Chris Herrera, LPC
Services
Blog
Contact

Call or Text

(480) 382-6109

Send A Message

Free Consultation

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Pediatric Nutrition Intake

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R.E.S.T.O.R.E. MNT · Sinnergy Wellness Group

Pediatric Nutrition Intake

Please take your time and provide as much detail as possible. Your responses are confidential and help us build care that truly fits your child and family.

1Who's Completing

2Demographics

3Care Team

4Records & Growth

5Medical History

6Developmental

7Repro / Hormonal

8Medications

9Nutrition Hx

10Typical Day

11Appetite & Cues

12Food Variety

13Special Diets

14Fluids

15Kitchen & Habits

16Activity

17Weight History

18Goals

19Admin

Company

This field is for validation purposes and should be left unchanged.

✍️ Who Is Completing This Form?

This form is being completed by:(Required)

Client (self)

Parent / Guardian

Both together

Caregiver

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

Relationship to client (if not the client)

What brings you to nutrition therapy?(Required)

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

Client initials(Required)

👤 About the Client

CUI#(Required)

Height (inches)

Birth Month

Birth Year

Gender Identity(Required)

Female

Male

Non-binary

Transgender female

Transgender male

Genderqueer

Prefer not to say

Prefer to self-describe

Self-describe (optional)

School / Occupation Status — select all that apply(Required)

In school (K–12)

Homeschooled

College / University

Employed

Unemployed

Other

If student — grade level or program

Household Structure — select all that apply(Required)

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

Describe any differences between homes (optional)

How did you hear about us?(Required)

Referring Provider

Website

Client Referral

Insurance Company

Online Directory

Other

🤝 Current Care Team

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

🧠 Therapist / Counselor / Psychologist — Allow contact?

Yes

🧠 Therapist / Counselor / Psychologist — Name

🧠 Therapist / Counselor / Psychologist — Practice

🧠 Therapist / Counselor / Psychologist — Phone

🧠 Therapist / Counselor / Psychologist — Fax

🧠 Therapist / Counselor / Psychologist — Reason seeing

🧠 Therapist / Counselor / Psychologist — 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?

Yes

🩺 Primary Care / Pediatrician — Name

🩺 Primary Care / Pediatrician — Practice

🩺 Primary Care / Pediatrician — Phone

🩺 Primary Care / Pediatrician — Fax

🩺 Primary Care / Pediatrician — Reason seeing

🩺 Primary Care / Pediatrician — How long have you worked with this provider?

< 1 yr

1–3 yr

4–10 yr

10+ yr

💊 Psychiatrist / Prescriber / APRN — Allow contact?

Yes

💊 Psychiatrist / Prescriber / APRN — Name

💊 Psychiatrist / Prescriber / APRN — Practice

💊 Psychiatrist / Prescriber / APRN — Phone

💊 Psychiatrist / Prescriber / APRN — Fax

💊 Psychiatrist / Prescriber / APRN — Reason seeing

💊 Psychiatrist / Prescriber / APRN — How long have you worked with this provider?

< 3 mo

3–6 mo

6–12 mo

1–2 yr

3+ yr

➕ Other Provider — Allow contact?

Yes

➕ Other Provider — Provider Type

➕ Other Provider — Name

➕ Other Provider — Practice

➕ Other Provider — Phone

➕ Other Provider — Fax

➕ Other Provider — Reason seeing

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)(Required)

Date(Required)

MM slash DD slash YYYY

📈 Records & Growth Data

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)

Describe special testing or additional records

Date of last bloodwork

MM slash DD slash YYYY

Next scheduled bloodwork

MM slash DD slash YYYY

Date of last vitals

MM slash DD slash YYYY

Next scheduled vitals

MM slash DD slash YYYY

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

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 (Optional)

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, heic, Max. file size: 20 MB, Max. files: 10.

Growth curves, blood work, labs, PCP notes, EKG/DEXA results. PDF, JPG, PNG, HEIC. Max 20MB per file.

🏥 Medical & Health History

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 — select any that apply

Diabetes / Prediabetes

High Blood Pressure (Hypertension)

High Cholesterol

Thyroid Disorder (Hypo/Hyperthyroidism)

Anemia / Low Iron

Vitamin D Deficiency

PCOS / Hormonal Imbalance

Gastrointestinal Issues (IBS, GERD, Reflux)

Lactose Intolerance / Food Intolerances

Food Allergies (List in detail)

Celiac Disease / Gluten Sensitivity

Kidney Disease / Stones

Liver Disease / Elevated Enzymes

Heart Disease / Arrhythmia

Stroke / TIA

Cancer (Current or Past)

Osteopenia / Osteoporosis

Arthritis / Chronic Pain

Migraines / Headaches

Depression

Anxiety

ADHD / Learning Disorder

Eating Disorder (AN, BN, BED, ARFID, OSFED)

Sleep Disorder / Insomnia

Gallbladder Disease / Removed

Asthma

Allergies (Seasonal / Environmental)

Autoimmune Disease (Specify)

Chronic Fatigue / Fibromyalgia

Neurological Conditions (Seizures, MS, etc.)

Substance Use Disorder

Other (Specify)

Select everything that currently or previously applied to the client.

Details on any diagnoses selected above (dates, notes)

Family Medical History — same list, for immediate family members

Diabetes / Prediabetes

High Blood Pressure (Hypertension)

High Cholesterol

Thyroid Disorder (Hypo/Hyperthyroidism)

Anemia / Low Iron

Vitamin D Deficiency

PCOS / Hormonal Imbalance

Gastrointestinal Issues (IBS, GERD, Reflux)

Lactose Intolerance / Food Intolerances

Food Allergies (List in detail)

Celiac Disease / Gluten Sensitivity

Kidney Disease / Stones

Liver Disease / Elevated Enzymes

Heart Disease / Arrhythmia

Stroke / TIA

Cancer (Current or Past)

Osteopenia / Osteoporosis

Arthritis / Chronic Pain

Migraines / Headaches

Depression

Anxiety

ADHD / Learning Disorder

Eating Disorder (AN, BN, BED, ARFID, OSFED)

Sleep Disorder / Insomnia

Gallbladder Disease / Removed

Asthma

Allergies (Seasonal / Environmental)

Autoimmune Disease (Specify)

Chronic Fatigue / Fibromyalgia

Neurological Conditions (Seizures, MS, etc.)

Substance Use Disorder

Other (Specify)

Select any conditions present in the client's immediate family.

Details on family history selected above (who, and any relevant notes)

Additional family history notes

🌱 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.

Describe what's been going on with eating, health, or body recently(Required)

"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?(Required)

🔬 Reproductive & Hormonal Health

This section applies to clients of all genders. Please skip any items that don't apply.

Select any that apply

Puberty onset — age when physical changes began

Early puberty (before age 8 in girls, 9 in boys)

Delayed puberty

Growth spurts — timing and pattern notable

Family history of delayed puberty or growth disorders

Menstrual history — age of first period (menarche)

Regular cycles (21–35 days typical)

Period length and flow normal (3–7 days)

Amenorrhea — Primary (never started by age 15)

Amenorrhea — Secondary (stopped for >3 months)

Functional Hypothalamic Amenorrhea (stress, wt loss, exercise)

History of low body weight or rapid weight loss

Low energy availability / chronic undereating

Excessive exercise or training load

RED-S features (fatigue, injury, stress fracture)

Cold intolerance / low resting HR / low BP

Stress fractures or low bone density history

History of DEXA scan (include date and result in detail)

Adequate calcium and Vitamin D intake

Use of hormonal therapy (estrogen, progesterone, testosterone)

PCOS / Endometriosis diagnosis

Thyroid disorder affecting hormones

Low testosterone symptoms (males or on labs)

Fatigue or cold extremities

Hair loss / dry skin / brittle nails

Mood changes related to hormone shifts

Family history of osteoporosis or hormone disorders

Your responses here are completely confidential.

Details on anything selected above (dates, notes)

Additional hormonal, reproductive, or endocrine notes

💊 Medications & Supplements

Prescription medications(Required)

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 type preference

Whole milk

2% milk

1% / Skim

Lactose-free

Fairlife

Almond milk

Oat milk

Soy milk

No dairy

Protein / meat preference

Chicken / poultry

Beef

Pork

Fish / seafood

Eggs

Vegetarian

Vegan

Pescatarian

🥗 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 — foods you enjoy or would like included

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

Fear foods — foods that cause significant anxiety

Please be as honest as you're comfortable.

Foods currently avoided and why

Who prepares meals, how often, and where?

Who do you usually eat with?

Alone

Family

Friends

Partner

It varies

How are meals typically served?

Family-style (serve yourself)

Pre-plated by someone else

Pre-portioned containers

I plate my own food

Varies

School or work lunch

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

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

🍽 Typical Day of Eating

Please give the best example of how the client eats on a typical day within the past month. Include approximate times and what was eaten and drunk. Be as detailed as possible — this is one of the most valuable parts of the intake.

Meal 1 · Time

Hours

Minutes

AM/PM

Meal 1 · Foods & Beverages

Snack 1 · Time

Hours

Minutes

AM/PM

Snack 1 · Foods & Beverages

Meal 2 · Time

Hours

Minutes

AM/PM

Meal 2 · Foods & Beverages

Snack 2 · Time

Hours

Minutes

AM/PM

Snack 2 · Foods & Beverages

Meal 3 · Time

Hours

Minutes

AM/PM

Meal 3 · Foods & Beverages

Snack 3 · Time

Hours

Minutes

AM/PM

Snack 3 · Foods & Beverages

Meal 4 · Time

Hours

Minutes

AM/PM

Meal 4 · Foods & Beverages

Snack 4 · Time

Hours

Minutes

AM/PM

Snack 4 · Foods & Beverages

Additional notes about this typical day

🧠 Appetite, Tolerance & Hunger Cues

Overall appetite

Good

Fair

Poor

Ability to recognize hunger cues

Good

Fair

Poor

Ability to recognize satisfaction cues

Good

Fair

Poor

Ability to recognize fullness cues

Good

Fair

Poor

Tolerance of current diet overall

Good

Fair

Poor

Details or comments on any of the above

🥦 Food Variety — Current Intake

For each food group, note how often the client eats from it and their most common foods. This gives us a detailed picture of intake variety over the past month.

Food Variety · Dairy & Alternatives

Food Variety · Grains & Starches

Food Variety · Protein Foods

Food Variety · Fruits

Food Variety · Vegetables

Food Variety · Fats

Food Variety · Beverages

Food Variety · Desserts & Sweets

Food Variety · Snacks

Food Variety · Restaurant Foods

🥑 Special & Modified Diets

For each diet pattern, indicate whether the client currently follows it.

Diet patterns currently followed — select all that apply

Vegetarian (Lacto-ovo, lacto, ovo)

Vegan (No animal products)

Pescatarian (Fish + plant-based)

Gluten-Free

Dairy-Free

Keto / Very Low Carb (<50g carbs/day)

Paleo

Intermittent Fasting (16:8, OMAD, etc.)

Low-Carb

Low-Fat

Low-Salt / Low-Sodium

Religious / Cultural (Kosher, Halal, Lent)

Medical diet (renal, diabetic, cardiac)

Low-FODMAP

Commercial (WW, Noom, Optavia)

Meal replacement / detox (shakes, cleanses)

Notes — frequency, duration, or other details

Who recommended this diet (if applicable)?

Doctor / PCP

Dietitian

Therapist

Self-directed

Social media

Family

N/A

How strictly is the diet followed?

Very strict — rarely deviate

Flexible — mostly follow it

On and off

N/A — no special diet

💧 Fluids & Beverages

For each beverage, enter amount and frequency. Leave blank if not consumed.

Plain water · Amount/Day

Plain water · Frequency

Sparkling water · Amount/Day

Sparkling water · Frequency

Juice · Amount/Day

Juice · Frequency

Milk · Amount/Day

Milk · Frequency

Coffee · Amount/Day

Coffee · Frequency

Tea · Amount/Day

Tea · Frequency

Energy drinks · Amount/Day

Energy drinks · Frequency

Electrolyte drinks · Amount/Day

Electrolyte drinks · Frequency

Soda — regular · Amount/Day

Soda — regular · Frequency

Soda — diet · Amount/Day

Soda — diet · Frequency

Nutrition shakes / ONS · Amount/Day

Nutrition shakes / ONS · Frequency

Smoothies · Amount/Day

Smoothies · Frequency

Alcohol · Amount/Day

Alcohol · Frequency

Other beverages not listed

🍳 Meal Planning, Shopping & Cooking

Meal & Snack Planning

Grocery Shopping

Food Prepping

Cooking

Portioning

Packing (meals for school, activities, travel)

Select All That Apply

I can cook for myself

I know my way around the kitchen

I can cook without a recipe

I prefer to follow recipes

I don't feel confident in the kitchen

I don't like to cook

I don't know how to cook

Someone in my household cooks for me

I use home meal delivery (HelloFresh, Sunbasket, etc.)

I often use food delivery (Uber Eats, DoorDash, GrubHub)

I eat out more than 3× per week

I grocery shop in-store

I shop online / use grocery pickup or delivery

I batch cook

I meal prep for the week

I prefer pre-portioned foods

I pre-plan meals and snacks for the week

I'd like to learn how to plan meals better

Additional details

How many meals to plan for at once?

1 at a time

3 meals

5 meals

7 days

Don't pre-plan

Want to learn

How often do you like leftovers?

Never

1 extra day

2 extra days

3 extra days

Batch cook dinners

Dislike leftovers

Prep Time Available — Breakfast

None / skip

5 min

15 min

30 min

1 hour

No limit

Prep Time Available — Lunch

None / grab out

5 min

15 min

30 min

1 hour

No limit

Prep Time Available — Dinner

Takeout / delivery

15 min

30 min

1 hour

No limit

🏃 Exercise, Sports & Activity

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

Activity 1 · Type

Activity 1 · Frequency

Activity 1 · Intensity

Activity 1 · Duration

Activity 1 · Pre/Post Fueling

Activity 2 · Type

Activity 2 · Frequency

Activity 2 · Intensity

Activity 2 · Duration

Activity 2 · Pre/Post Fueling

Activity 3 · Type

Activity 3 · Frequency

Activity 3 · Intensity

Activity 3 · Duration

Activity 3 · Pre/Post Fueling

Additional notes on activity, movement, or physical limitations

⚖️ Weight History & Perception

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

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 — where

At home (daily)

At home (occasionally)

At doctor's office only

Smart scale / MyClearStep

Avoids being weighed

Treatment facility only

Weighing Practices — preferred style

Blind (not told the number)

Open (sees number)

Prefers to avoid weighing entirely

No preference

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?

🎯 Goals of Nutrition Therapy

Goal 1

Goal 2

Goal 3

Goal 4

Goal 5

What feels most important for us to talk about first?

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

📄 Administrative

Will you need a Superbill for out-of-network insurance reimbursement?(Required)

Yes

Not sure yet

Unless otherwise confirmed with the practice manager, superbills are issued in the first week of each month for the prior month's sessions. You'll receive an email notification when yours is ready.

Insurance carrier

Member ID

Group number

Policy holder name

Best way to reach you

Phone / text

Healthie portal

Best email address

Acknowledgment & Consent. By signing below, I confirm the information provided in this intake form is accurate and complete to the best of my knowledge. I understand it will be used by Sinnergy Wellness Group to provide individualized nutrition care.

Full Name (signature)(Required)

Date(Required)

MM slash DD slash YYYY

Sinnergy Wellness Group is Attested, Innovative, & Effective Treatment Solutions For Eating Disorders.

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info@sinnergywellness.com

8700 E. Vista Bonita Dr. Suite 236
Scottsdale, AZ 85255

Office Hours

Tue & Thu: 12PM - 8PM
Sat: 9AM - 5PM In Person & Telehealth

2026

Notice of Privacy Practices. No Surprises Act.

Pediatric Nutrition Intake

Pediatric Nutrition Intake

✍️ Who Is Completing This Form?

👤 About the Client

🤝 Current Care Team

📈 Records & Growth Data

🏥 Medical & Health History

🌱 Developmental History

🔬 Reproductive & Hormonal Health

💊 Medications & Supplements

🥗 Nutrition History

🍽 Typical Day of Eating

🧠 Appetite, Tolerance & Hunger Cues

🥦 Food Variety — Current Intake

🥑 Special & Modified Diets

💧 Fluids & Beverages

🍳 Meal Planning, Shopping & Cooking

🏃 Exercise, Sports & Activity

⚖️ Weight History & Perception

🎯 Goals of Nutrition Therapy

📄 Administrative

Follow Us

Quick Links

MyClearStep Scales

#HowToMealPlan

Contact Us

Office Hours

Schedule with Sinnergy Wellness Group

ARE YOU A NEW CLIENT?

• • •

ARE YOU A CURRENT CLIENT?

Family/ Loved Ones Group Interest

Adult Group Interest

Adolescent/ Teen Group Interest