Patient Forms

These forms are for patients of Feed To Succeed to fill out prior to their first appointment. Our office will provide instructions on which forms to complete. Please submit completed forms to or fax to 847.728.8221.

Patient Intake Form

Please fill out this form and bring it to your first appointment. The form collects patient data, payment information, and obtains your agreement to our policies.

Early Intervention Policies

This document provides our policies for our Early Intervention patients.

Feed to Succeed Food Log

Before your first appointment, please provide 3-4 days of food and symptom records for your child prior to his/her appointment. Use the form below, or track electronically with the MyFitnessPal app.

Nutrition Assessment Tool

Please provide information on the diet and symptoms of the patient before his/her first visit.

How To Measure Your Infant or Toddler at Home (Age 0 – 2 years)

How To Measure Your Child at Home (Age 2 – 18 years)