Prenatal Diet Questionnaire Form
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1Prenatal Diet Questionnaire
Your Name: _____________________________________________________ Birth Date: ___/___/_____ Today’s date: ___/___/_____
1.
Please check all of the following you have that work.
Stove Top
Oven
Microwave
Refrigerator
2.
How many times do you eat each day?
Meals _____ Snacks _____
3.
Are there any foods or beverages that you cannot or will not eat?
No
Yes, please list ____________________________________
4.
Are there any foods of which you think you do not eat enough?
No
Yes, please list ____________________________________
5.
What do you usually drink? (Please check all that apply.)
Milk
Water
Juice/Juice Drinks
Gatorade/Sports Drinks
Wine/Beer/Alcoholic Drinks
Coffee/Tea
Herbal Teas
Hot chocolate
Regular Pop/Kool-Aid
Diet Pop
Other: _________________________________________________________
6.
How often do you drink milk?
Several times/day
Once/day
Less than once/day
Do not drink milk
What type of milk do you usually drink?
Cow’s (_____Whole (Vitamin D) _____Reduced/Low Fat (2%, 1% or ½%) _____Skim)
Lactose Free
Evaporated
Sweetened Condensed
Soy
Rice
Goat’s
Raw (Cow’s or Goat’s)
Other: _________________________________________________________________
7.
How many times do you eat fruits and vegetables during a normal day?
________________
Do not eat any fruits or vegetables
Which fruits and/or vegetables (not juice) do you usually eat? (Please check all that apply.)
Bananas
Grapes
Apples/Applesauce
Oranges
Pears
Carrots
Green Beans
Potatoes
French Fries
Corn
Sprouts
Tomato
Other: ________________________________________________________________________
8.
How many times do you eat protein foods during a normal day? ____________
Do not eat protein foods
9.
Which protein foods do you usually eat? (Please check all that apply.)
Beef/Buffalo
Chicken/Turkey
Fish/Seafood
Pork/Lamb
Hot Dogs/Lunch Meat
Meat Spreads/Pâté
Dried/Canned Beans
Eggs
Tofu
Yogurt
Soft Cheese (Feta, Brie, Blue-Veined, and Queso Fresco)
Hard Cheese (American, Cheddar, Swiss…)
Other ________________________________________________________________________________________________
10. Do you ever eat anything that is not food, such as ashes, chalk, clay, dirt, large quantities of ice, or starch (laundry/cornstarch)?
No
Yes
11. Are you on a special diet?
No
Yes, please describe _____________________________________________________________
12. How much weight do you think you should gain with this pregnancy? ________________ pounds
13. Have you seen a doctor for this pregnancy?
No
Yes, date of your first visit? ___/___/______ # of visits
______________
14. Are you expecting twins, triplets, etc?
No
Yes
15. Are you having any problems/complications with this pregnancy?
Heartburn
Nausea and vomiting
Gestational diabetes
High blood pressure
Constipation
Diarrhea
Weight loss
Other, please describe
__________________
16. Do you have any medical/health/dental problems?
No
Yes, please list ___________________________________________
Was this problem diagnosed by a doctor / dentist?
No
Yes
17. Please check and describe all of the following you routinely use. (All information given to the WIC Program is confidential.)
Over-the-counter drugs (laxatives, pain killers, etc.) _____________________________________________________________
Prescription medication ______________________________________________________________________________________
Vitamin and/or minerals supplements ___________________________________________________________________________
Herbs/Herbal Supplements (Echinacea, ginger, etc.) _____________________________________________________________
Tobacco
Street drugs (Marijuana, cocaine, methamphetamines, etc.)
Other: ____________________________________
18. Have you had a blood lead test?
No
Unsure
Yes, where? _______________________________________________
19. Not including this time, how many times have you been pregnant?
________________
(If this is your first pregnancy stop here)
When did your last pregnancy end? ___/___/______
Are you currently breastfeeding a baby/child?
No
Yes
Please check any of the following that were true with any of your previous pregnancies.
My baby was born more than 3 weeks early
My baby was born weighing less than 5 pounds 9 ounces
My baby was born weighing 9 pounds or more
My baby was born with a birth defect
My doctor told me I had gestational diabetes
I have had no complications
Other, please list ___________________________________________________________________________________________
10/2012
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