Diet Questionnaire Form - Toddler (6-24 Months)
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2Toddler (6 - 24 months) 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.)
Breastmilk
Formula
Cow’s Milk
Goat’s Milk
Sweetened Condensed Milk
Evaporated Milk
Soy Milk
Water
Juice/Juice Drinks
Regular Pop/Kool-Aid
Sweetened Tea
Herbal Tea
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 bottle or a sippy cup?
No
Yes
5.
How is breastfeeding going?
_______________________________________________________
Child not breastfed
a.
How often does your child nurse in a 24-hour period? ________________
b.
Can you hear your child swallowing during feedings?
No
Yes
6.
How many wet diapers does your child have in a 24-hour period? ________________
7.
How many dirty diapers does your child have in a 24-hour period? ________________
8.
Do you pump or express breastmilk for your child?
No
Yes
a.
How do you store breastmilk?
Refrigerator
Freezer
Other _______________________________________
b.
How long do you keep breastmilk in the refrigerator before you throw it away? ________________ hours
c.
How long do you keep breastmilk after it’s been thawed? ________________ hours
9.
Please check all items that might be in your child’s bottle during a normal day.
Child does not take a bottle
Milk (including breastmilk)
Formula
Water
Juice/Juice Drinks
Cereal
Soda Pop/Kool-Aid/Sweetened Tea
Corn Syrup
Honey
Baby Food
Other __________
a.
What do you do with any milk or formula left in the bottle?
Leave it out to feed later
Put it back into the refrigerator for later
Throw it away
Other _________________
b.
How long do you let a bottle sit at room temperature? ________________ hours
c.
Is your child’s bottle ever propped on a pillow, blanket, stuffed animal, etc.?
No
Yes
10. What formula does your child take? ____________________________ (
with iron
low iron)
Child does not take formula
a.
What type of formula do you use?
Concentrate
Powder
Ready-to-feed
b.
How do you mix the formula? ________ amount water to ________amount formula
i.
What kind of water do you usually use to make the formula?
City/Rural
Well
Bottled
Unsure
ii. Do you ever add anything besides water to the formula?
No
Yes, what?
_________________________
c.
Do you warm the formula?
No
Yes, how? __________________________________________________
d.
How often does your child take formula during a normal day? ____________
e.
How much formula does your child take at each feeding? ________________ ounces
f.
How do you store formula after you mix it?
Don’t store, give to child right away
Refrigerator
Freezer
Other ________________________________
g.
How long do you keep mixed formula in the refrigerator before you throw it away? ________________ days
h.
How long does a can of formula last?
___________________________________________________________________
11. 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 ½%)
_____Skim)
Lactose Free
Goat’s
Evaporated
Sweetened Condensed
Soy
Rice
Other: __________
c.
Do you ever add any flavoring to the milk?
No
Yes, what?
___________________________________________
12. 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?
______________________________________________
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