Center for Human Nutrition
Medical Nutrition Syllabus
Guide to Healthy Diet and Lifestyle
Exercise Guidelines
Managing Obesity
Exercise Prescription
Medicine and Surgery Nutrition Assessment Checklist
Pediatric Nutrition Assessment Checklist
Adolescent Nutrition Assessment Checklist
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PEDIATRIC NUTRITION ASSESSMENT CHECKLIST
(This checklist is to prompt you during patient interviews You are required to fully complete this and turn it in with your nutrition write-up and growth charts. Include information that is relevant
on the write-up.)
Present Illness:
Medical History:
Is your child allergic to any food or drinks? Yes / No Do they get a rash or exema Yes / No
If yes, allergic reaction to what?
______________________________________
Does your child take any vitamins / minerals or food supplements? Yes / No
If yes, which ones?____________________________________with fluoride Yes / No
If your child is not taking a vitamin, does your water supply contain fluoride? Yes / No
Social History:
What type of milk are you feeding your child? _____________# ounces drank/day?______
If you feed your child formula, how much do you give and how much water do you add?
_______________________________________________________
What else does your child drink during the day? Ice tea Soda Diet soda
Kool aid Juice Water Hawaiian punch other_______
Is your child put to bed with a bottle? Yes / No
If your child is eating foods, when did you start to introduce solid foods into their diet?
___________________
How many meals does your child eat during the day?________________
How many snacks does your child eat during the day?________________
Does your child usually eat the food that is prepared for the family? Yes / No
Does your child avoid any specific foods such as milk or meats? Yes / No
If yes, which ones?______________________________
Does your child chew on any:
Dirt Clay Paint chips Woodwork Ice Plaster Newspaper
How old is your house? Do you have lead pipes? Yes/No Has the water been tested for lead?
Yes/No
Review of Systems:
General:__________________________________________________________
Skin:____________________________Hair:____________Nails:____________
Head:____________________________________________________________
Eyes: ____________________________________________________________
Mouth: ___________________________________________________________
GI/Abdomen: ______________________________________________________
Cardiac: __________________________________________________________
Extremities: _______________________________________________________
Neurological: ______________________________________________________
Musculoskeletal: ____________________________________________________
Height (Length):______(cm) Height for Age:____________(%ile)
Current weight:_______(kg) Weight for Age:___________(%ile)
Ideal Weight for height:_______(kg) Ideal height for age:_______(cm)
If weight change? (days, weeks or months)__________
Head circumference (cm): (%ile)______(For children < 3 years old- use growth chart)
% Weight for Height:______________ Interpretation:_________________
% Height for Age:_______________ Interpretation:__________________
Laboratory Evaluation:
Serum Albumin:_________________
Significance:_______________________________________________________
Serum Transferrin:___________________
Significance: _______________________________________________________
Serum Glucose (normal = 70 - 1 10 mg/dl))________________
Significance: _______________________________________________________
Hematocrit and Hemoglobin_____________________
Significance: _______________________________________________________
Serum Cholesterol:________________________
Significance: _______________________________________________________
Serum Triglycerides:_______________________
Significance: _______________________________________________________
Other relevant lab data:
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