Pediatric Digestive Health Assessment Form
Please complete this assessment to help us understand your child's digestive health. All information is confidential and used solely for clinical evaluation.
Child's First Name and Last Initial
*
Child's Age
*
Primary digestive concerns (select the most relevant)
*
Abdominal pain
Constipation
Diarrhea
Vomiting
Bloating/gas
Feeding difficulties
Other
How often does your child experience digestive symptoms?
*
Rarely (less than once a week)
Occasionally (1-2 times per week)
Frequently (3 or more times per week)
Daily
Please rate the severity of your child's digestive symptoms.
*
1
2
3
4
5
Bowel Movement Patterns
*
Rows
Never
Rarely
Sometimes
Often
Always
Straining
1
2
3
4
5
Hard stools
6
7
8
9
10
Loose stools
11
12
13
14
15
Painful bowel movements
16
17
18
19
20
Does your child experience abdominal pain?
*
No
Yes, mild
Yes, moderate
Yes, severe
How often does your child experience nausea or vomiting?
*
Never
Rarely
Sometimes
Frequently
Does anyone in the family have a history of digestive disorders?
*
No
Yes, parent(s)
Yes, sibling(s)
Yes, extended family
How much do digestive symptoms interfere with your child's daily activities (school, play, etc.)?
*
Not at all
1
2
3
4
Severely
5
1 is Not at all, 5 is Severely
Submit Assessment
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