Toddler (6 - 24 months) Diet Questionnaire
Child’s Name: _____________________________________ Child’s Birth Date: ___/___/_____ Today’s date:
Please check all of the following you have that work.
What does your child usually drink? (Please check all that apply.)
Sweetened Condensed Milk
From what does your child drink? (Please check all that apply.)
Does your child ever walk around drinking from a bottle or a sippy cup?
How is breastfeeding going?
Child not breastfed
How often does your child nurse in a 24-hour period? ________________
Can you hear your child swallowing during feedings?
How many wet diapers does your child have in a 24-hour period? ________________
How many dirty diapers does your child have in a 24-hour period? ________________
Do you pump or express breastmilk for your child?
How do you store breastmilk?
How long do you keep breastmilk in the refrigerator before you throw it away? ________________ hours
How long do you keep breastmilk after it’s been thawed? ________________ hours
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)
Soda Pop/Kool-Aid/Sweetened Tea
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
How long do you let a bottle sit at room temperature? ________________ hours
Is your child’s bottle ever propped on a pillow, blanket, stuffed animal, etc.?
10. What formula does your child take? ____________________________ (
Child does not take formula
What type of formula do you use?
How do you mix the formula? ________ amount water to ________amount formula
What kind of water do you usually use to make the formula?
ii. Do you ever add anything besides water to the formula?
Do you warm the formula?
Yes, how? __________________________________________________
How often does your child take formula during a normal day? ____________
How much formula does your child take at each feeding? ________________ ounces
How do you store formula after you mix it?
Don’t store, give to child right away
How long do you keep mixed formula in the refrigerator before you throw it away? ________________ days
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
How much milk does your child drink each time?
What type of milk does your child usually drink?
(_____Whole (Vitamin D) _____Reduced/Low Fat (2%, 1% or ½%)
Do you ever add any flavoring to the milk?
12. How many times does your child drink water during a normal day? __________
Child does not drink water
How much water does your child drink each time?
What kind of water does your child usually drink?
Do you ever add anything to the water?