Early Head Start Child Nutrition History Form
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1Head Start/Early Head Start Child Nutrition History
13-60 Months
Child’s Name: _______________________________
Center: _________________________
YES
NO
Number of Servings
1. Does your child require any type of therapeutic or
FOOD
special diet? Please describe:
Daily
Weekly
#
#
Milk
Cheese
Yogurt
YES
NO
2. Does your child require any special adaptive
Meat
feeding equipment to eat or drink? If yes, please
Fish
describe:
Eggs
Peanut Butter
Beans (pinto, lima, soy, garbanzo,
kidney, blackeyed peas, split
peas, tofu, lentils)
3. Does your child need assistance eating\drinking?
YES
NO
Cereal
Bread
Please describe:
Tortillas
Crackers
Rice
Noodles
YES
Candy, Sweets, Desserts
4. Does your child have trouble chewing or
NO
swallowing? If yes, please describe:
Sugar rich beverages: sodas,
punch, Kool-Aid, Hi-C
YES
NO
5. Do you have any questions or concerns about the
Sugar Coated Cereal
way your child is eating? Please describe:
YES
NO
Water
6.
Does your child drink caffeine-containing drinks
such as Coke, Pepsi, tea or coffee two or more
times a day?
YES
NO
7. Does your child ever eat non-food items such as
dirt, clay, paint chips? Please describe:
8. Who usually makes your child’s meals?
Oranges, Grapefruit or Juice,
Vitamin C rich fruits (cantaloupe,
kiwi, strawberries, tangerine,
papaya, tomato or juice, salsa,
9. What times does your child usually eat?
cabbage, brussel sprouts,
broccoli).
Breakfast___________ Lunch____________
Dinner_____________ Snack____________
Mango, Carrots, Cantaloupe,
10. Are you currently receiving WIC services?
YES
NO
Yams, Apricots, Deep Yellow
(Women, Infants & Children Services)
Squash
WIC verification: WIC I.D.
#___________________________________
If no, would you like more information?
Dark Leafy Greens (Spinach,
11. Would you like more information on the following?
chard, bok choy, romaine, etc.)
____Ways to Stretch Food Dollars
_____ Facts on Food Labels
____How Do I Get My Child to Eat
_____ Keep Your Food Safe
____Basic Nutrition: MyPlate.gov
_____ WIC & Food Stamps
Other:________________________________________________
st
st
1
Year Parent Signature _________________________________ Date _________ 1
Year Staff Signature _________________________________ Date ________
nd
nd
2
Year Parent Signature _________________________________ Date _________ 2
Year Staff Signature _________________________________ Date ________
Follow-up information is located on Family Contact Form.
White – Child’s File
Canary – Parent
Distribution:
H/N Services 059
Revised 8/15
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