Form Dhcs 4035 B - What Do You Eat - State Of California Health And Human Services Agency Forms
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1State of California—Health and Human Services Agency
Department of Health Care Services
Child Health and Disability Prevention (CHDP) Program
What Do You Eat?
(Ages 8-19)
Office use only:
Circle the names of foods you eat often:
Circle to indicate the topics discussed:
Iron/Protein
Healthy eating
Chicken/Turkey
Ham/Pork
Seafood
Eggs
Tofu
Regular meals/snacks
Importance of breakfast
Hamburger
Fried Chicken Tacos
Peanut Pizza
Inadequate food supply
Whole Grain Bread
Peanut Butter
Cereal
Rice
Hot dog
Low fat dairy foods
Meat/Bean Burrito
Noodle Soup
Tortilla
Beef
Pasta
High sugar foods
Other: ___________________________
Sweet Bread
Beans/Lentils White Bread
Potato
Iron/Protein
Dark Green Leafy Vegetables
Spaghetti with Meatballs
2-3 servings daily
Fruits and Vegetables
High iron foods
Cucumber
Broccoli
Banana
100% Juice Pear
Pea
Plant protein sources such as
Pineapple
Bell pepper
Orange
Carrots
Apple
Mango
beans, peas, lentils, nuts, etc.
Cantaloupe Chili Pepper
Tomato
Grapes
Potato
Corn
Limit high fat foods
Green Salad Cabbage
Green Beans
Peach
Melon
Fruits and Vegetables
Strawberry
Dark Green Leafy Vegetables
Sweet Potato
2-4 fruits daily or more
Snack
3-5 vegetables daily or more
Vitamin C sources
Chocolate
French Fries
Fruit Pie
Donut
Candies
Vitamin A sources
Vegetables
Cheese Puffs Chips
Cookies
Bagels
Calcium
Mexican Bread
Popcorn
Pretzels
Crackers
Fruits
3-4 servings dairy foods/day
Nonfat or 1 % milk
Drinks
Lowfat dairy choices
Sports Drinks
100% Fruit Juice
Wine
Soda
Low lactose alternative
Calcium fortified foods
Alcoholic Drink
Flavored Drinks
Coffee
Beer
Other food sources of calcium
Sweetened Tea
Wine Cooler
Herbal Tea
Tea
Snacks
Fruit Flavored Soda
Coffee Drink
Energy Drinks Water
High-sugar snacks
Calcium
High-fat snacks
Fruit/vegetable snacks
Almond butter
Nonfat Milk
Whole Milk
2 % Milk Prunes
Fast foods
1 % Lowfat Milk
Tempeh
Tahini
Yogurt
Beans
Drinks
Lactose Free Milk Ice Cream
Dried Figs
Cheese
Tofu
< 8-12 oz/day 100% juice
Cottage Cheese
Milkshake
Soy Beans
Almonds Corn
6-8 glasses of water (8 ounces each)/day
Sweetened drinks
Green Leafy Vegetables
Orange
Tortilla
Alcohol/caffeine
Calcium Fortified 100% Juice
Calcium Fortified Soy/Plant Milk
Referred for identified
Name: _____________________ Age: _____ Date of Birth: _________
nutrition problem?
Yes
No
Wt: _____ lbs Ht: _____ in BMI: _____ BMI %ile: _____ Date: ______
If yes, where: ______________________
Provider initials: ____________________
DHCS 4035 B (05/16) Adapted from the CHDP Programs of Orange County and San Bernardino Counties
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