Form 4777t-E - Food History - Riverside County Division Of Children And Family Services
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1Division of Children and Family Services
Early Childhood Education Programs
Food History
Child’s Name: ___________________________________________________________ DOB: ___________________ M F
Parent/Guardian Name: ___________________________________________________ Phone: ___________________________
Primary Language:
English
Spanish
Other (Specify): ______________________________________________
Head Start Site: __________________________________________________________ Date: _____________________________
Nutrition is a very important part of our program. In order for us to meet your child’s nutritional needs, please answer the
following questions regarding your child’s eating pattern.
1. Is your child now allergic to, or intolerant of, any foods? Yes No If yes, medical statement form required.
What foods? ______________________________________________________________________________________________
2. Is your child allergic or intolerant of any beverages such as milk? Yes No If yes, doctor’s note is required.
3. Are medications required at school?
Yes No If yes, doctor’s note is required.
4. Is your child now on a special diet?
Yes No If yes, doctor’s note is required.
What foods? ______________________________________________________________________________________________
5. Does your child have trouble chewing or swallowing? Yes No If yes, explain: ________________________________
6. Is your child currently on the Women, Infant, and Children (WIC) Program? Yes No
7. Is your family currently receiving Supplemental Nutrition Assistance Program (SNAP)? Yes No
8. At what times does your child eat the following meals and snacks?
Meal
How many days per week
Time
Meal
How many days per week
Time
Breakfast
A.M. Snack
0
0
Lunch
P .M. Snack
0
0
Dinner
Bedtime Snack
0
0
9. What foods does your child like? ____________________________________________________________________________
10. What foods does your child dislike? __________________________________________________________________________
11. How much water does your child drink each day?
1 cup 2 cups 3 cups 4 cups 5 cups 6 cups 7 cups 8 cups
12. Does your child take vitamin or mineral supplements? Yes No
If yes, what kind? __________________________
13. Does your child now eat dirt, clay or other non-food items? Yes No If yes, explain: ___________________________
________________________________________________________________________________________________________
14. Does your child take a bottle? Yes No
FORM NO. 4777T-E
(Revised 05/15)
DISTRIBUTION: White - Child’s File Yellow - Grantee/Nutritionist
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