Baby Health Intake Form Your Name * First Name Last Name Child’s Name First Name Last Name Child’s DOB MM DD YYYY Email * Address Does your child have any disorders, diseases, or health complications? (Past or present) Have they been introduced to purees yet? Have they been introduced to finger foods yet? Have there been any concerns about introducing purees or finger foods so far? Does your family follow a specific diet? (Vegan, vegetarian, paleo, etc.) Are there any food groups or individual foods that you avoid giving your child for any reason? Are there any foods that your child rejects eating? Do they have any foods allergies? (Suspected or confirmed) Do they have any food sensitivities? (Suspected or confirmed) Has your child ever experienced a reaction after eating any food? Do they currently have eczema, or have they had eczema in the past? Please click the check boxes that apply. Has your child been introduced to the following flavors? Sweet Sour Spicy Salty Has your child been introduced to the following allergenic foods? Cow’s Milk Wheat Hen’s Eggs Peanuts Tree Nuts Fish Shellfish Soy Does your child’s diet include? Gluten Grains Dairy Animal Proteins Sugar List any nutritional supplements your child takes and what they take them for. (Vitamin, mineral, herbal, homeopathic, etc.) Are they currently breastfed or formula-fed? If they do not breastfeed, were they ever breastfed? If so for how long, and when did they wean? List any beverages other than breast milk/formula that your child consumes. (Water, juice, etc.) Was your child born vaginally or by cesarean section? Have they been given antibiotics at any point in their life? Are bowel movements consistent and regular? Do they experience constipation or diarrhea? Is there anything that you hope to change about your child’s current diet or eating habits? Is there anything else to share about your child’s health status? (Please be as thorough as possible) Are there any specific questions or concerns you would like addressed? Thank you for contacting Whole Baby. I will be in contact as soon as possible.
