Diet Questionnaire Form - Toddler (6-24 Months) Page 2
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213. How many times does your child drink juice during a normal day? __________
Child does not drink juice.
a.
How much juice does your child drink each time?
__________________ounces
b.
What kind of juice or juice drinks does your child usually drink?
______________________________________________
c.
Do you dilute the juice with water?
No
Yes
14. When did your child start eating something other than breastmilk or formula?
Hasn’t started yet
0-3 month
4-6 months
after 7 months
a.
What types of food does your child eat? (Please check all that apply.)
Baby foods
(___ Cereal, ___ Fruits, ___ Vegetables, ___ Meats, __Dinners, __ Desserts)
Table foods
(___ Mashed/blended, ___ Finely chopped, ___ Coarsely chopped/sliced)
Other:
_________________________________________________________________________________________
b.
At mealtimes, how often does your child eat the same foods as the rest of the family?
Most of the time
Sometimes
Rarely, what does your child eat?
____________________________
c.
How is your child fed these foods? (Please check all that apply.)
Bottle
Spoon
Fingers/Self-feeding
d.
Can your child feed him/herself?
No
Yes
15. How many times does your child eat on a normal day?
Meals _____ Snacks _____
16. Please mark the situations that describe where your child normally eats. (Check all that apply.)
In a bed/crib
In caregiver’s arms /lap
In a car seat
In a high chair
At a table
On the sofa
At home
In a restaurant/fast food
In the car
At childcare/Head Start/preschool
With the TV on
With family / friends
Alone
Other:
____________________________
17. Which snack foods does your child usually eat? (Please check all that apply.)
Child does not eat snack foods
Fruit
Fruit Snacks
Cookies / Snack Cakes
Honey Graham Crackers
Cereal / Cereal Bars
Nuts
Chips
Hard Candies
Popcorn
Pretzels
Crackers
Ice Cream
Other _________________________
18. How many times does your child eat fruits and vegetables (not juice) during a normal day?
______
Which fruits and/or vegetables does your child usually eat? (Please check all that apply.)
Does not eat fruits or vegetables
Apples/Applesauce
Bananas
Grapes
Oranges
Pears
Potatoes
French Fries
Corn
Green Beans
Carrots
Sprouts
Tomato
Other:
_______________________________________
19. How many times does your child eat protein foods during a normal day?
______________
Child does not eat protein foods
Which protein foods does your child usually eat? (Please check all that apply.)
Beef/Buffalo
Chicken/Turkey
Fish/Seafood
Dried/Canned Beans
Hot Dogs/Lunch Meat
Peanut Butter
Pork/Lamb
Eggs
Tofu
Yogurt
Hard Cheese (American, Cheddar, Swiss…)
Soft Cheese (Feta, Brie, Blue-Veined, and Queso Fresco)
Other __________________________________________
20. Which sweets does your child usually eat? (Please check all that apply.)
Child does not eat anything sweet
Sugar
Honey
Syrup
Candy
Other ______________________________________________
How are they usually eaten? (Please check all that apply.)
Added to/in drinks
In pre-sweetened drinks
On the pacifier
Added to/on foods
In sweet foods (candies, cookies, cakes etc)
Other ____________________________
21. Does your child regularly eat anything that is not food, such as dirt, paper, crayons, pet food or paint chips?
No
Yes
22. Does your child have any health/medical/dental problems?
No
Yes, please list:
____________________________
Was this problem diagnosed by a doctor?
No
Yes
23. Please check and describe all of the following your child usually takes.
Over-the-counter drugs (cold medicine, pain killers, etc.)
______________________________________________
Prescription medication ___________________________________________________________________________
Vitamin and/or minerals supplements _________________________________________________________________
Herbs/Herbal Supplements (Echinacea, ginger, etc.)
______________________
Other _________________________
24. Do you worry about how much your child is eating?
No
Yes, please explain ________________________________
25. Has your child had a blood lead test?
No
Yes
Unsure
If yes, where? ____________________ When? ___/____/______ What were the results?
_____________________
26. What is one thing you like about your child’s eating? ____________________________________________________________
27. What is one thing that you would like to change about your child’s eating? __________________________________________
Toddler Diet Questionnaire
10/2012
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