Feeding Disorders Questionnaire Page 6
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7Food Preference Checklist
Child’s name ______________________________________________
Is your child on a special diet? _________________________________
Food Allergies _____________________________________________
Food Restrictions ___________________________________________
Please circle all foods your child eats and label any specific brands.
Cereal – List:
Starches:
Bread
Spaghetti
Oatmeal
Rice
Waffles
French fries
Noodles
Pancakes
Mashed potatoes
Macaroni & cheese
French toast
Baked potato
Corn
Muffins
Fruits:
Orange juice
Fruit cocktail
Orange
Apple juice
Peach
Banana
Grape Juice
Pear
Strawberries
Watermelon
Pineapple
Apple
Cantaloupe
Applesauce
Dried Fruit
Vegetables:
Green beans
Lettuce/salad
Spinach
Carrots
Broccoli
Tomatoes
Peas
Peppers
Sweet potato
Milk – Type
Milk/Dairy:
Soy/Almond Milk
Pudding
Yogurt – type
Chocolate/Flavored Milk
Cheese
Ice Cream
Meat/
Chicken
Fish
Eggs
Protein:
Chicken nuggets
Fish sticks
Grilled cheese
Hamburger
Sausage
Peanut butter
Ham
Pork
Nuts
Roast Beef
Hot Dogs
Other:
Turkey
Steak
Mixed
Pasta with sauce
Pizza
Sandwiches
Textures:
Tacos/burritos
Casseroles
Other:
Extras:
Margarine
Mayonnaise
Syrup
Jelly
Salad dressing
Mustard
Ketchup
Cream cheese
Other:
Snacks:
Cookies
Pretzels
Water
Chips
Crackers
Soda
Poptarts
Goldfish
Kool-aid
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Parent category: Medical