Nutrition Assessment: 0-15 years This form is to understand your diet in order to better help you. Please answer the questions when applicable. If not, please skip the question.* Required Nutrition Assessment : 0-15 years Name of Child * Name of Child First First Last Last Email * Blood Type * Select Blood TypeO+O-A+A-B+B-AB+AB- What is the reason for your child nutrition visit? * Child is not eating enough Child is a picky eater Child is overweight Child is underweight No issues, it is a preventive visit to understand what should my child be eating at this age Child is starting solids and I would like to understand what he/she should be eating other OtherOther Name of parent filling out the form * Name of parent filling out the form First First Last Last Telephone number for parent * Area Code Telephone number * Phone Number Child's Date of birth * Does your child exercise per day? * 0-30 minutes 30 minutes-1 hour 1-2 hours No time at all None but willing to exercise for 30 minutes 3 times a week None but capable of exercising 1 hour 3 times a week or more Medications Does your child have any health problems ? * High cholestrol Hypetension Diabetes OtherOther Please mention your main concerns and all questions you would like to be answered in the consultation To be confirmed later with Le Gabarit Somebody from our clinic will follow up with you to settle payment reCAPTCHA If you are human, leave this field blank. Submit