DIETARY QUESTIONNAIRE FOR CHILDREN
Pennsylvania Department of Health -- WIC Program
  • / /
  • Please fill in the blanks and check all answers that apply.

  • Daily Some days Never
    Meats, chicken, fish:
    Grains (pasta, rice, bread, cereal, tortilla):
    Fruits:
    Eggs:
    Vegetables:
    Peanut butter:
    Cheese:
    Beans (pinto, kidney, etc.):
H511.867 (Rev.5/16)