Fillable Child (2-5 years) Diet Questionnaire

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Child (2-5 years) Diet Questionnaire

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The Child (2-5 years) Diet Questionnaire form is 2 pages long and contains:

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  • 111 check-boxes
  • 69 other fields

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Child (2-5 years) Diet Questionnaire
Child's Name: Child's Birth Date:
/
/
Today's Date:
/ /
1) Please check all of the following you have that work:
Stove Top Oven Microwave Refrigerator
2) What does your child usually drink? (Please check all that apply)
Milk (including breastmilk) Formula Juice/Juice Drinks Water Sweetened Tea Regular Pop/Kool-Aid
Herbal Teas Gatorade/Sports Drinks Other:
3) From what does your child drink? (Please check all that apply)
Breast Bottle Sippy Cup Cup
4) Does your child ever walk around drinking from a sippy cup or a bottle?
No
Yes
5) How many times does your child drink milk during a normal day?
Child does not drink milk
a) How much milk does your child drink each time?
ounces
b) What type of milk does your child usually drink?
Cow's
(
Whole (Vitamin D) Reduced/Low Fat (2%, 1% or 1/2%) Skim
)
Lactose Free Goat's Evaporated Sweetened Condensed Soy Rice
Other:
c) Do you ever add flavoring to the milk?
No
Yes
6) How many times does your child drink water during a normal day?
Child does not drink water
a) How much water does your child drink each time?
ounces
b) What kind of water does your child usually drink?
City/Rural Well Bottled Unsure
c) Do you ever add anything to the water?
No Yes
, what?
7) How many times does your child drink juice during a normal day?
Child does not drink juice
a) How much juice does your child drink each time?
ounces
b) What kind of juice or juice drinks does your child usually drink?
c) Do you dilute the juice with water?
No Yes
8) At mealtimes, how often does your child eat the same foods as the rest of the family?
Most of the time Sometimes Rarely
, what does your child eat?
a) What types of food does your child eat? Please check all that apply.
Baby foods Table foods
(
Mashed/blended Finely Chopped Coarsely chopped/sliced
)
b) Can your child feed him/herself?
Page 1 of 2
No Yes
9) How many times does your child eat on a normal day?
Meals Snacks
10) What do you do when your child asks for food between meals and snacks?
11) Please mark the situations that describe where your child normally eats. (Check all that apply)
In a high chair At a table On the sofa On the floor
At home In a restaurant/fast food In the car At childcare/Head Start/preschool
With the TV on With family/friends Alone
Other:
12) Which snack foods does your child usually eat? (Please check all that apply) Child does not eat snack foods
Fruit Fruit Snacks Cookies/Snack Cakes Crackers Chips Popcorn Nuts Pretzels
Ice Cream Cereal/Cereal Bars Hard Candies Other:
13) How many times does your child eat fruits and vegetables (not juice)during a normal day?
Child does not eat fruits and vegetables
Which fruits and/or vegetables (not juice) do you usually eat? (Please check all that apply)
Apples/Applesauce Bananas Grapes
Oranges Pears Potatoes French Fries Corn Green Beans Carrots
Sprouts
Tomato
Other:
14) How many times does your child eat protein foods during a normal day?
Child does not eat protein foods
Which protein foods does your child usually eat? (Please check all that apply)
Beef/Buffalo Chicken/Turkey Fish/Seafood
Pork/Lamb Hot Dogs/Lunch Meat Dried Beans Peanut Butter Eggs
Tofu
Yogurt
Hard Cheese (American, Cheddar, Swiss...) Soft Cheese (Feta, Brie, Blue-Veined, Queso Fresco
Other:
15) Which sweets does your child usually eat? (Please check all that apply) Child does not take anything sweet
Sugar Honey Syrup Candy Other:
How are they usually eaten? (Please check all that apply)
Add to/in drinks In pre-sweetened drinks On the pacifier Added to/on foods
In sweet foods (candies, cookies, cakes, etc. Other:
16) Does your child regularly eat anything that is not food, such as dirt, paper, crayons, pet food or paint chips? No Yes
17) Does your child have health/medical/dental problems?
No
Yes
, please list:
Was this problem diagnosed by a doctor?
No
Yes
18) Please check and describe all of the following your child usually takes.
Over-the-counter drugs (laxatives, pain killers, etc.)
Prescription medication
Vitamin and/or mineral supplements
Herbs/Herbal Supplements (Eshinacea, ginger, etc.)
Other:
19) Do you worry about how much your child is eating?
No Yes
, please explain:
20) Has your child had a blood lead test?
No Yes Unsure
21) What is one thing you like about your child's eating?
22) What is one thing that you would like to change about your child's eating?
If yes, where?
When?
/
/
What were the results?
23) How much time does your child spend actively playing each day?
hours
24) About how many hours does your child sit and watch TV, videos or DVDs on a normal day?
hours/day
Child does not usually watch any TV, videos or DVDs
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Child (2-5 years) Diet Questionnaire

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Completed 13 August 2020

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