Child & Family Nutrition Intake Form – WellClinica

Child Name

First

Last

DOB

Parent/Guardian Name(s):

First

Last

Phone

Email

Medical & Growth History

Was your child born full-term?

If No please explain

Any diagnosed medical conditions or allergies?

If yes please explain:

Current medications or supplements:

Bowel movement frequency:

Daily Routine & Sleep

Describe a typical weekday (wake-up, meals, school, snacks, bedtime):

Sleep duration (hours/night):

Any trouble falling asleep, waking up at night, or tiredness during the day?

Eating Habits & Food Choices

Does your child eat at the school cafeteria or bring lunch?

Typical breakfast:

Typical lunch:

Typical dinner:

Typical snack:

digestion? kitchen school,

How often does your child eat

At the table
In front of screens
While distracted?

Does your child help in the kitchen or choose snacks?

Favorite foods:

Foods they refuse or dislike:

How often does your child eat takeout, fast food, or restaurant meals?

Rarely
1–2x/week
3+ times/week

How often does your child eat takeout, fast food, or restaurant meals?

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Is your child physically active or enrolled in sports/athletics?

If yes, what sport(s) and how many hours/week?

Do they feel energized or tired after activity?

Do they eat before or after physical activity?

What types of food?

Behavior, Focus & Mood

Any recent changes in behavior, mood swings, or emotional eating?

Any concerns with attention, focus, or hyperactivity during school or homework?

Do you suspect certain foods affect their behavior or digestion?

Family Food Culture & Nutrition Goals

How many meals per week does your family eat together?

Do you follow any family eating guidelines?

(e.g., no screens at meals, limited sugar, reward system?)

What are your top priorities for this nutrition consultation?

Consent

I consent to a functional nutrition consultation for my child with WellClinica for lifestyle-based wellness recommendations.
I confirm that I am the parent/legal guardian of the child listed above and that the information provided is accurate to the best of my knowledge.

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