Postpartum Woman Nutrition Questionnaire Form - California Department Of Public Health - Wic Program
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1State of California — Health and Human Services Agency
California Department of Public Health — WIC Program
Postpartum Woman Nutrition Questionnaire
Name:
Age:
Please circle or write your answers to the following questions:
1.
What is something that you do to be healthy? ________________________________________________________________________
2.
What would you like to talk about today? ___________________________________________________________________________
Your Eating Habits
3.
How do you feel about how you are eating now?
Good
OK
Not so good
Other
4.
How many meals do you eat each day?
How many snacks?
5.
How many times a week do you eat out or eat take-out food?
0
1
2
3
4
5
6
7
more
Drinks and Foods
6.
What do you drink on most days?
Water
Milk
Juice
Soda
Coffee
Tea
Flavored water
Fruit drinks
Kool-Aid or Punch
Diet drinks
Energy drinks
Sports drinks
Soy milk
Wine
Beer
Alcohol
Other _________________________________________________________________________________
7.
What do you eat on most days?
Whole wheat bread
Corn tortillas
Whole wheat tortillas
Brown rice
Cold or hot cereal
White bread
Flour tortillas
White rice
Pasta/Noodles
Crackers
Vegetables (which?) _________________________________________________________
How many each day? _______________
Fruits (which?) ______________________________________________________________
How many each day? ______________
Beef
Pork
Chicken
Turkey
Fish
Eggs
Beans
Peanut butter
Nuts
Tofu
Nonfat milk
Lowfat milk
Whole milk
Flavored milk
Cheese
Yogurt
Cottage cheese
French fries
Chips
Hot dogs
Deli meats
Nuggets
Desserts/sweets
Other _________________________
8.
Are you on a special diet?
No
Yes (please explain) _______________________________________________________________
9.
Are there any foods that you limit or avoid?
No
Yes (please explain)
____________________________________________
Additional Questions
10.
Do you have:
Diabetes (high blood sugar)
High blood pressure
Anemia (low iron in blood)
Mental health issues
Depression
Other ______________________________________________________________
None
11.
How do you feel about your weight?
Want to lose weight
OK
Want to gain weight
12.
Which of these do you take?
Prenatal vitamins
Multivitamins with folic acid
Other vitamins/minerals
Iron pills
Laxatives
Herbs
Over the counter medicines
Prescription medicines
Home remedies
Other _________________________________________________________________________________
None
13.
How have you been feeling?
Not interested in doing things
Sad
Depressed
Hopeless
No energy
Happy
OK
Lonely
Overwhelmed
Stressed
Anxious
Angry
Other __________________________________
14.
What kinds of physical activities do you do? ____________________________________
How often? _______________________
15.
If breastfeeding, how is it going for you? _____________________________________________________________________________
16.
What support will you need to keep breastfeeding if you return to work or school?
Pump
Other _____________________
17.
Do you plan to have more children?
Yes (when?) ________________________________________________
No
Not sure
18.
What plans do you have for birth control? ____________________________________________________________________________
19.
When is your next doctor’s appointment? _____________________________ Last dentist appointment? _____________________
20.
Do you ever run out of food?
No
Yes (what do you do?) _________________________________________________________
21.
What questions or concerns do you have about shopping for WIC foods? _______________________________________________
__________________________________________________________________________________________________________________
Date:
Staff Name: _____________________________________________________
STAFF
USE ONLY
WIC ID#:
Height:
Weight: __________
This institution is an equal opportunity provider.
CDPH 4153 10/14
Postpartum
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