EmailMeForm
DIETARY QUESTIONNAIRE FOR WOMEN
Pennsylvania Department of Health -- WIC Program
Endorser's Name
First
Last
Date
MM
/
DD
/
YYYY
Please fill in the blanks and check all answers that apply.
1. Do you have any medical problems?
No
Yes
Dental problems or cavities?
No
Yes
Please list or describe:
Do you take any medicine?
No
Yes
Please list:
Do you have any problems with your current pregnancy?
No
Yes
Not applicable
Please list or describe:
Have you ever had problems with a previous pregnancy or delivery?
No
Yes
Please list or describe:
In the past few weeks, have you been feeling down or depressed, or lost interest in doing things you enjoy?
No
Yes
2. Do you have frequent problems with any of the following:
Nausea
Vomiting
Diarrhea
Heartburn
Chewing food
Poor appetite
Gas
Cramps
Constipation
None of these
3. Are you on a special diet such as Vegetarian, Low Carbohydrate or Macrobiotic?
No
Yes
If yes, describe:
Do you feel you need to cut down on any of the following?
No
Yes
If yes, which ones?
Sugar
Calories
Salt
Fat
Carbohydrate
Other
4. Do you take any of these?
No
Yes
If yes, which ones?
Prenatal Vitamin
Multivitamin
Folic Acid
Vitamin D
Iron
Iodine
Herbal teas/supplements
Other
5. Do you crave or eat any of the following?
No
Yes
If yes, which ones?
Laundry starch
Soil
Chalk
Paint chips
Cigarette ashes
Ice (in large quantities)
Burnt matches
Clay
Carpet fibers
Cornstarch
Other
6. Do you eat any of these foods:
Raw cookie dough or cake batter
Hot dogs, deli or lunch meats
Bean sprouts
Raw or undercooked eggs, meat, or fish
Soft cheese like feta or brie
Milk, juice or cider from a mill or farm (if unpasteurized)
7. Check which items you have at home that work:
Running water
Stove
Refrigerator
Freezer
Microwave
Do you have a thermometer in the refrigerator or freezer?
No
Yes
If yes, what is the refrigerator temperature?
Freezer temperature?
8. 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
Are different cutting boards for fruits/vegetables and raw meats?
No
Yes
9. Check how often you eat 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.):
10. How many meals do you eat each day?
1
2
3 or more
How many times a day do you eat snacks?
1
2
3 or more
None
Check the foods that you eat for snacks:
Cookies
Crackers
Chips
Pretzels
Cereal
Cereal bars
Cheeses
Yogurt
Fruit
Pudding
Vegetables
Candy
Other
11. Are you allergic to any foods?
No
Yes
Which foods:
Seafood
Peanuts/Nuts
Eggs
Wheat
Soy
Milk/dairy products
Other
12. How much milk do you drink each day?
Less than 1 cup
1 to 2 cups
3 or more cups
Do not drink milk
Check which kinds of milk you drink:
Whole
2%
1%
Skim
Lactose free
Chocolate/Strawberry
Goat's milk
Soy milk
Almond milk
Rice milk
Other
13. Check what beverages you drink:
Soda or Pop
Kool-Aid
100% Juice
Drinks in boxes, pouches, etc.
Juice drinks (Hawaiian Punch, Hi-C, Sunny D etc.)
Tea
Gatorade
Energy drinks
Coffee
Water
None of these
Other
14. How often do you eat at fast food places such as Burger King or McDonalds?
Every day
A few times a week
Once a week
Once a month or less
15. Other than work, how many hours per day do you watch TV or use the computer or the cell phone?
1 or less
2
3
4 or more
16. How often do you get 30 minutes or more of physical activity (walking, running, playing with kids, etc.?)
Every day
3-5 days per week
Once per week
Seldom
17. Do you have a family history of weight problems?
No
Yes
18. Do you use any of the following?
No
Yes
Cigarettes - How many per day?
Alcohol (Beer,Wine, Liquor) - How much per day?
Street Drugs - What kinds and how often?
Do you have a history of drug or alcohol use?
No
Yes
19. Does anyone smoke in your home?
No
Yes
20. Do you ever have to choose between buying food and paying bills?
A lot
Sometimes
Rarely
Never
What questions do you have about nutrition or your diet?
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H511.865 (Rev.5/16)