A Look at Your Childs Nutrition
Office Use Only ID#___________________
Location _____________________________
FRC ________________________________
Nutrition Screening Form
Todays Date: ______________________
Childs Name: ____________________________ Age: _________________ Birth date:_______________
male
female
Your Name:______________________________ Phone #:___________________ Relationship to child::____________________
Address: ________________________________ City: ______________________ State: ______________ Zip: ______________
Birth weight: ______________________________
Was your child premature (born early)?
yes
no
Did you breastfeed your child?
yes
no
(2 pts if < 2 y.o. and LBW or PM)
If yes, how many weeks early? _____________
If yes, for how long? ______________________
The following questions will help us learn more about your child. Please answer each of the following questions.
1.
How does your child appear to you?
overweight (3)
underweight (4)
just right
short (2)
If available, what is your childs most recent: weight ___________ height ___________ date of measurement: ___________
2.
Do any of the following apply to your childs food intake? ...........................................
yes (3)
no
If yes, check all that apply.
3.
refuses many foods
drinks more than 40oz. milk per day (5 cups)
eats too much
refuses solid foods
has poor appetite
eats too little
eats fewer than 3 times per day
other: _________________________________________________________________
Does your child have any feeding or eating problems? ...................................................
yes (4)
no
If yes, check all that apply.
difficulty sucking
difficulty feeding self
chokes on solids
difficulty chewing foods
chokes on liquids
loses food from mouth
using bottle after age 2 years
difficulty drinking from a cup
takes a long time to eat
other: _______________________________________________________________________________________________
4.
Does your child have a feeding tube? ...........................................................................
yes (5)
no
5.
Is your child on a special diet for a medical condition (e.g., diabetes, PKU,)?
yes (4)
no
If yes, what kind?_________________________________________________________________________________________
6.
Is your child allergic to, or intolerant of, any foods? .......................................................
yes (2)
no
If yes, what foods?________________________________________________________________________________________
7.
Does your child often have diarrhea? ...........................................................................
yes (3)
no
8.
Does your child often have constipation? ........................................................................
yes (2)
no
9.
Does your child often vomit?...........................................................................................
yes (3)
no
10. In the past six months was your child found to be anemic (low blood iron)?..................
yes (2)
no
11. Does your child currently have dental problems?............................................................
yes (1)
no
12. Does your child take medications? ..................................................................................
yes (2)
no
If yes, what medications and for how long? ____________________________________________________________________
_______________________________________________________________________________________________________
13. Does your child take vitamins/minerals/home remedies/herbal products? ......................
yes (1)
no
If yes, name of supplement(s)? ______________________________________________________________________________
14. Does your child eat any non-food items (clay, dirt, starch,) ........................................
yes (4)
no
If yes, specify: ___________________________________________________________________________________________
15. What is your childs activity level?
walks independently
does not walk
needs help walking (braces/walker) (2)
not old enough to walk
16. Do you have trouble buying enough food to feed your family? ......................................
yes (3)
no
17. Does your child participate in any of the following programs? Check all that apply.
WIC
ITN/CSHCN
Early Intervention Provider
Public Health Nurse
SSI
Medicaid
Private Insurance
Food Stamps
Foster Care
DDD
School District
Home Health
Head Start/Early Head Start
Feeding Clinic
Other:____________________________________________________
18. Do you have any additional concerns about your childs growth, nutrition or eating?....
yes (1)
no
If yes, what are your concerns? ______________________________________________________________________________
19. Is your child currently receiving nutrition services? .......................................................
yes
no
If yes, name of person or agency: ____________________________________________________________________________
Childs Ethnicity (check major one):
Caucasian
Hispanic/Latino
American Indian
African American
Asian/Pacific Islander
Other/Unknown
Multi-Racial
Childs Medical Diagnosis (check any which apply):
Asthma/Pulmonary Disease
Congenital heart disease
Cystic Fibrosis
Metabolic/endocrine disorders
Renal (kidney) disease
Other:
Autism Spectrum Disorder
Cerebral Palsy
Developmental delay
Muscular Dystrophy
Sensory impairment (blind, deaf)
Bronchopulmonary Disease (BPD)
Chromosome disorder (i.e., Down Synd.)
Epilepsy/seizures
Neurological disorder
Spina Bifida
Cancer
Cleft lip/palate
Gastrointestinal disorder
Orthopedic problems
Unknown diagnosis
Children with Special Health Care Needs
1101 West College Avenue, Suite 240
Spokane, WA 99201-2095 (509) 324-1651
www.srhd.org
This screening form was adapted with permission from USC
University Affiliated Program, Childrens Hospital, Los Angeles.
SRHD/CSHCN March, 2004
