EmailMe Form - DIETARY QUESTIONNAIRE FOR CHILDREN

Name
First Last
Endorser Name
First Last
Date Time
MM / DD / YYYY
Please fill in the blanks and check all answers that apply.
1. Does your child have any medical problems?
No
Yes
Dental problems or cavities?
No
Yes
Does your child take any medicine? If so, please list:
2. Is your child on a special diet such as Vegetarian or Macrobiotic?
No
Yes
If yes, please describe:
Do you limit any of the following in your child's diet?
No
Yes
Multiple Choice
Sugar
Calories
Salt
Fat
Carbohydrate
Other
Reason:
3. Does your child take any of the following?
Multivitamins
Fluoride
Vitamin D
Iron
Herbal teas/supplements
Other
4. Describe how you defrost foods:
Under running water
In the refrigerator
On the counter
In the microwave
Does everyone was their hands before and after food preparation?
No
Yes
Do you use different cutting boards for fruits/vegetables and raw meats?
No
Yes
5. Check which items you have at home that work:
Running water
Stove
Refrigerator
Freezer
Microwave
If you have a thermometer in the refrigerator, what is the temperature?
Freezer temperature?
6. How much milk does your child drink each day?
Less than 1 cup
1 to 2 cups
3 or more cups
Does not drink milk
Check which kinds of milk your child drinks:
Whole
2%
1%
Skim
Lactose free
Chocolate/Strawberry
Goat's milk
Soy milk
Almond milk
Other
7. Check what other beverages your child drinks:
Soda/Pop
Kool-Aid
100% Juice
Drinks in boxes, pouches, etc.
Juice drinks (punch, cocktail, etc.)
Tea
Gatorade
Energy drinks
Other
Do you add water to these beverages?
No
Yes
8. Does your child drink plain water?
No
Yes
How much each day?
Less than 1 cup
1 to 2 cups
3 or more cups
9. Does your child use a bottle?
No
Yes
What goes in the bottle?
Does your child go to sleep with the bottle or walk around with it during the day?
No
Yes
10. Does your child use a sippy cup?
No
Yes
Describe when:
Meals
Snacks
Walks around with it
Goes to sleep with it
11. Does your child eat baby foods?
No
Yes
Describe the texture:
Blended smooth
With chunks
Does your child eat table foods?
No
Yes
Describe the texture:
Mashed
Finely chopped
Chunky
Regular
12. Is your child able to self-feed?
No
Yes
Describe how:
Spoon
Fork
Fingers
Other
13. Is your child having any problems with:
Poor appetite
Food textures
Chewing food
Swallowing food
Nausea or vomiting
Diarrhea
Constipation
None of these
14. Is your child allergic to any foods:
No
Yes
Which foods:
Seafood
Peanuts
Nuts
Eggs
Wheat
Soy
Milk
Other
15. How many meals does your child eat each day?
1
2
3 or more
Besides meal time, when is your child given something to eat?
At snacks
When fussy or crying
Do you offer food as a reward?
No
Yes
If yes, what foods?
Do you require your child to eat certain foods or finish plate?
No
Yes
16. Check any concerns you have with getting your child to eat well:
Picky eater
Leaves food on the plate
Wants the same foods all the time
Begs for snacks between meals
Wants milk or juice all day
None of these
Other
17. Besides your home, where does your child usually eat?
Day care/baby sitter
Head start
Relatives
Usually at home

18. Check how often your child eats the foods listed below:

	Daily	Some days	Never
Meats, chicken, fish:
Grains (pasta, rice, bread, cereal, tortilla):
Fruits:
Eggs:
Vegetables:
Peanut butter:
Cheese:
Beans (pinto, kidney, etc.):

19. How many times a day does your child eat snacks?
1
2
3 or more
Check the foods your child eats for snacks:
Cookies
Crackers
Chips
Pretzels
Cereal
Cereal bars
Candy
Cheese
Yogurt
Fruit
Pudding
Vegetables
Other
20. How often does your child eat at fast food places such as Burger King or McDonalds?
Everyday
A few times a week
Once a week
Once a month
Never
21. How many hours a day does your child spend watching TV, playing video games or using the computer or phone?
1 or less
2
3 or more
22. Does you child eat any of these foods? If yes, please check.
Popcorn
Whole grapes
Hard candy
Lollipops
Raw vegetables
Nuts or seeds
Peanut butter
Gummies
Jelly beans
Hot dogs
Pretzels
Chips
Raisins/dried fruit
Other
Does you child eat any of these foods? If yes, please check.
Raw cookie dough or cake bater
Hot dogs, deli or lunch meats
Raw or undercooked eggs, meat, or fish
Soft cheese like feta or brie
Bean sprouts
Milk, juice or cider from mill or farm (if unpasteurized)
23. Does anyone smoke inside your home?
No
Yes
24. Does you child eat any of the following?
Laundry starch
Soil
Chalk
Paint chips
Cigarette ashes
Ice (in large quantities)
Burnt matches
Clay
Carpet fibers
Corn starch
Foam rubber
Other
25. Has you child been tested for lead?
No
Yes
26. Do you ever have to choose between buying food and paying bills?
A lot
Sometimes
Rarely
Never
27. What questions do you have today about your child's nutrition or diet?

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Please fill in the blanks and check all answers that apply.