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HISTORY
1. Has your child been diagnosed with any of the following?
diabetes
high blood pressure
autism spectrum disorder
cancer
kidney disease
irritable bowel
inflammatory bowel disease(crohn's, colitis etc)
Anorexia/ Bulemia/ Binge eating disorder
Failure to Thrive
Asthma
Cystic Fibrosis
Obesity
prematurity
2. Does you child have any medical conditions that would require a special diet? if so please explain
3. Does your child have any allergies? if so, please list ( include food, medication)
4. Please List all Current Medications
5. Please list all current supplements ( i.e. vitamins, minerals, herbals, nutritional supplements)
6. Who prepares/ serves your child's meals?
7. Has your child had any significant weight gain or loss in the past 6 months?
8. What is your main reason for seeking nutrition counseling?
9. Anything else you would like Mandi to know.......
