Patient's Last Name:
* must provide value
Patient's First Name:
* must provide value
Is your child an established patient of VCU Health?
* must provide value
Yes No Unsure
What is the best telephone number to contact for registration and scheduling?
* must provide value
Date of Birth:
* must provide value
Today M-D-Y
Was your child full-term at birth (37-42 weeks gestation)?
Yes No
Birth Weight Details:
(For a birth weight of 7 pounds and 2 ounces, select "7" under pounds and then "2" under ounces)
Mother's health condition(s) during this pregnancy: (Check all that apply)
If other, please describe:
Complications after birth: (Check all that apply)
If other, please describe:
During the first six (6) months of life, was your child:
Breastfed Formula fed Both
Did your child experience difficulty with suck, swallow and/or feeding?
Yes No
At what age did your child start eating solid foods (including rice cereal)?
Less than 1 month 1-3 months 4-6 months 7-9 months 10-12 months Greater than 12 months
Did your child experience difficulty gaining weight in early childhood?
Yes No
How would you describe your child's early development?
Normal Delayed
At approximately what age did your child start sitting independently:
4 months 6 months 9 months 12 months Greater than 12 months
At approximately what age did your child start standing independently:
9 months 12 months 14 months 16 months 18 months Greater than 18 months
At approximately what age did your child start walking independently:
9 months 12 months 16 months 18 months 24 months Greater than 24 months
At approximately what age did your child get their first teeth:
4 months 6 months 9 months 12 months 16 months Greater than 16 months
At approximately what age did your child become toilet trained:
12 months 18 months 24 months 3 years 4 years Greater than 4 years
Has your child experienced or had difficulty with low or decreased muscle tone?
Yes No
At any time, did you or your child's provider have concerns about your child's growth from a height standpoint?
Yes No
Do you or your child's provider have concerns about your child having early or delayed puberty?
Yes No
Age menstruation started, if applicable:
At what age did you first have concerns about your child's weight gain?
How would you best describe your child's weight gain?
Sudden Gradual
Please select your child's current or past medical problems. (Check all that apply)
If other, Please explain:
Has your child ever had any of the following major injuries? (Check all that apply)
Does your child take medications on a daily basis?
Yes No
Has your child ever taken the following medications/therapies? (Check all that apply)
Has your child ever had any of the following surgical procedures? (Check all that apply)
Who lives at home with the child? (Check all that apply)
If other, please describe:
What method of education does your child attend:
In-Person Virtual Hybrid (In-Person & Virtual)
What is your child's current grade level?
Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade Post-High School Technical Education College
What are your child's typical grades in school? (Check all that apply)
Have there been recent changes in your child's grades?
Yes No
Has your child had difficulty with attention, concentration, or sitting still in school?
Yes No
Has your child ever been suspended or expelled from school?
Yes No
Has your child ever been diagnosed with a learning disorder?
Yes No
Has your child every received Individual Education Plan (IEP) / 504 accommodation
Yes No
Has your child had problems with attendance at school?
Yes No
Mother's Height Details:
(For a height of 5 feet and 6 inches, select "5" under feet and then "6" under inches)
Mother current weight (lbs):
Mother's age at first period (menses):
Is mother currently employed?
Yes No
If yes, describe in what capacity:
Part-Time Full-Time
How much education did the mother complete:
Less than High School
High School Diploma/GED
Technical School/Vocational
Some College
College Graduate
Father's Height Details:
(For a height of 6 feet and 1 inches, select "6" under feet and then "1" under inches)
Father current weight (lbs):
Is father currently employed?
Yes No
If yes, describe in what capacity.
Part-Time Full-Time
How much education did the father complete:
Less than High School
High School Diploma/GED
Technical School/Vocational
Some College
College Graduate
Does this child have a sibling?
Yes No
Less than 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Greater than 18
Sibling 1's Height:
(For a height of 4 feet and 10 inches, select "4" under feet and then "10" under inches)
Does this child have more than one (1) sibling?
Yes No
Less than 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Greater than 18
Sibling 2's Height:
(For a height of 4 feet and 10 inches, select "4" under feet and then "10" under inches)
Sibling 2's weight (lbs):
Does this child have more than two (2) siblings?
Yes No
Less than 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Greater than 18
Sibling 3's Height:
(For a height of 4 feet and 10 inches, select "4" under feet and then "10" under inches)
Heart Disease / Heart Attack
Auto Immune Disease (Rheumatoid Arthritis, Lupus, Celiac)
Has anyone in the family ever had weight loss surgery?
Yes No
Has your child ever received outpatient counseling/therapy before?
Yes No
Is your child currently receiving therapy?
Yes No
If yes, please provide name & contact of current counselor:
Has your child ever taken medication for psychological reasons?
Yes No
Is your child currently taking medication for psychological reasons?
Yes No
Has your child ever been hospitalized for psychological reasons?
Yes No
Has anyone in the family been diagnosed or treated for a psychological problem?
Yes No
Has anyone in the family had a problem with alcohol or drugs?
Yes No
Are you aware of your child's use of any of the following: (Check all that apply)
Has your child ever engaged in self harm?
Yes No
Has your child ever been diagnosed with an eating disorder?
Yes No
What is the age of your child:
* must provide value
Who normally prepares the food in the house?
Mom
Dad
Grandparent
This Child
Sibling
Other
Who normally does the grocery shopping in the house?
Mom
Dad
Grandparent
This Child
Sibling
Other
In the last year, did you worry that your food would run out before you got money or food stamps to buy more?
Yes No
How many servings of fruits does your child eat on a typical day?
No regular servings of fruits 1-2 serving of fruit per day 3-4 serving of fruit per day 5 or more servings of fruit per day
How many servings of vegetables does your child eat on a typical day?
No regular servings of vegetables 1-2 serving of vegetables per day 3-4 serving of vegetables per day 5 or more servings of vegetables per day
How many meals does your child eat on a typical day?
No regular meals 1-2 meals per day 3-4 meals per day 5 or more meals per day
Does your child always eat breakfast?
Yes No
Does your child always eat lunch?
Yes No
Does your child always eat dinner?
Yes No
How many snacks does your child eat on a typical day?
No regular snacks
1-2 snacks per day
3-4 snacks per day
5 or more snacks per day
Select any of the following beverages that your child normally consumes on a typical day: (Check all that apply)
On a typical day, how many of these drinks does your child consume ?
None of these beverages
1-2 beverages per day
3-4 beverages per day
5 or more beverages per day
How many times per week do you eat as a family?
Never 1 2 3 4 5 or more
How many times per week does your child eat fast food?
Never 1 2 3 4 5 or more
Are you satisfied with your child's eating habits?
Yes No
Do you have concerns about your child's portion sizes?
Yes No
Does your child wake up at night to eat?
Yes No
Does your child ever eat in secret?
Yes No
Would you consider your child a grazer (eats all day)?
Yes No
Does it seem like your child only ever wants to eat "junk food" or "sweets?"
Yes No
Do you worry that your child can't control or loses control over how much he/she eats on a typical day?
Yes No
Does your child eat to make himself/herself happy, or to feel better?
Yes No
Does your child's weight affect how he/she feels about himself/herself?
Yes No
Does your child currently have or have ever had an eating disorder?
Yes No
Does your child have a TV in the room where they sleep?
Yes No
Does your child have a computer or electronic device in the room where your sleep?
Yes No
How many hours on a school day does your child watch TV/movies, sit at the computer, play video games, or sit spending time on your phone or tablet (Do not include school related activity)? ___________ hours/day
0 Hours
1 Hour
2 Hours
3 Hours
4 Hours
5 Hours
6 Hours
7 Hours
8 or more Hours
How many hours on the weekend does your child watch TV/movies, sit at the computer, play video games, or sit spending time on your phone or tablet (Do not include school related activity)? ___________ hours/day
0 Hours
1 Hour
2 Hours
3 Hours
4 Hours
5 Hours
6 Hours
7 Hours
8 or more Hours
How many times per week is your child active (ie. His/her heart pounds & his/her breathing gets faster)?
Never
1-2 days/week
3-4 days/week
5-6 days/week
Daily
What time on a school night does your child typically go to bed?
Before 9pm
Between 9pm and 10pm
Between 10pm and 11pm
Between 11pm and 12pm
After Midnight
What time on a school night does your child typically fall asleep after going to bed?
Before 9pm
Between 9pm and 10pm
Between 10pm and 11pm
Between 11pm and 12pm
After Midnight
What time on a school day does your child typically wake up?
Before 6am
Between 6am and 7am
Between 7am and 8am
Between 8am and 9am
Between 9am and 10am
After 10am
What time on a weekend night does your child typically go to bed?
Before 9pm
Between 9pm and 10pm
Between 10pm and 11pm
Between 11pm and 12pm
After Midnight
What time on a weekend night does your child typically fall asleep after going to bed?
Before 9pm
Between 9pm and 10pm
Between 10pm and 11pm
Between 11pm and 12pm
After Midnight
What time on a weekend day does your child typically wake up?
Before 7am
Between 7 and 8am
Between 8 and 9am
Between 9 and 10am
Between 10am and 11am
After 12pm
Does your child have any difficulties with the following: (Check all that apply)
Please indicate which of the following behaviors you are interested in helping your child and family to change: (Check all that apply)
What's one thing that you can do to get started with your new goal?
Who normally prepares the food in the house?
Mom
Dad
Grandparent
Brother/Sister
I do
Other
Who normally does the grocery shopping in the house?
Mom
Dad
Grandparent
Brother/Sister
I do
Other
In the last year, did you worry that food for your family would run out before having money or food stamps to buy more?
Yes No
How many servings of fruits do you eat on a typical day?
No regular servings of fruits 1-2 serving of fruit per day 3-4 serving of fruit per day 5 or more servings of fruit per day
How many servings of vegetables do you eat on a typical day?
No regular servings of vegetables 1-2 serving of vegetables per day 3-4 serving of vegetables per day 5 or more servings of vegetables per day
How many meals do you eat on a typical day?
No regular meals 1-2 meals per day 3-4 meals per day 5 or more meals per day
Do you always eat breakfast?
Yes No
Yes No
Do you always eat dinner?
Yes No
How many snacks do you eat on a typical day?
No regular snacks 1-2 snacks per day 3-4 snacks per day 5 or more snacks per day
Select any of the following beverages that you normally consume on a typical day: (Check all that apply)
On a typical day, how many of these drinks do you consume?
None of these beverages
1-2 beverages per day
3-4 beverages per day
5 or more beverages per day
How many times per week do you eat dinner with your family?
Never 1 2 3 4 5 or more
How many times per week do you eat fast food?
Never 1 2 3 4 5 or more
Do you worry that you can't control or lose control over how much you eat on a typical day?
Yes No
Do you ever eat in secret?
Yes No
Does your weight affect how you feel about yourself?
Yes No
Are you satisfied with your eating habits?
Yes No
Do you have concerns about your portion sizes?
Yes No
Does it seem like you only ever want to eat "junk food" or "sweets?"
Yes No
Do you eat to make yourself happy, or to feel better?
Yes No
Do you wake up at night to eat?
Yes No
Would you consider yourself a grazer (you eat all day)?
Yes No
Do you currently have or have you ever had an eating disorder?
Yes No
Do you have a TV in the room where you sleep?
Yes No
Do you have a computer or electronic device in the room where your sleep?
Yes No
How many hours on a school day do you watch TV/movies, sit at the computer, play video games, or sit spending time on your phone or tablet (Do not include school related activity)? ___________ hours/day
0 Hours
1 Hour
2 Hours
3 Hours
4 Hours
5 Hours
6 Hours
7 Hours
8 or more Hours
How many hours on the weekend do you watch TV/movies, sit at the computer, play video games, or sit spending time on your phone or tablet (Do not include school related activity)? ___________ hours/day
0 Hours
1 Hour
2 Hours
3 Hours
4 Hours
5 Hours
6 Hours
7 Hours
8 or more Hours
How many times per week are you active (ie. Your heart pounds & your breathing gets faster)?
Never
1-2 days/week
3-4 days/week
5-6 days/week
Daily
What time on a school night do you typically go to bed?
Before 9pm
Between 9pm and 10pm
Between 10pm and 11pm
Between 11pm and 12pm
After Midnight
What time on a school night do you typically fall asleep after going to bed?
Before 9pm
Between 9pm and 10pm
Between 10pm and 11pm
Between 11pm and 12pm
After Midnight
What time on a school day do you typically wake up?
Before 6am
Between 6am and 7am
Between 7am and 8am
Between 8am and 9am
Between 9am and 10am
After 10am
What time on a weekend night do you typically go to bed?
Before 9pm
Between 9pm and 10pm
Between 10pm and 11pm
Between 11pm and 12pm
After Midnight
What time on a weekend night do you typically fall asleep after going to bed?
Before 9pm
Between 9pm and 10pm
Between 10pm and 11pm
Between 11pm and 12pm
After Midnight
What time on a weekend day do you typically wake up?
Before 7am
Between 7 and 8am
Between 8 and 9am
Between 9 and 10am
Between 10am and 11am
After 12pm
Do you have any difficulties with the following: (Check all that apply)
Please indicate which of the following behaviors you are interested in changing for yourself: (Check all that apply)
What's one thing that you can do to get started with your new goal?