Breastfeeding / Postpartum Woman Nutrition Questions
ADVERTISEMENT
1State of California—Health and Human Services Agency
Department of Health Services
WIC Supplemental Nutrition Branch
BREASTFEEDING / POSTPARTUM WOMAN NUTRITION QUESTIONS
Name:
Age:
Please circle or write your answers to the following questions:
1. When is your next doctor’s appointment?
Has your doctor talked to you about family planning / birth control?
Yes
No
2. How is breastfeeding going for you?
(Circle one)
(not good) 1
2
3
4
5 (great)
. . . . . . . . .
. . . . . . . . .
. . . . . . . . . . . . . . . . . .
3. Which of these do you take?
Prenatal Vitamins
Iron Pills
Herbs
Other Vitamins / Minerals
Laxatives
Over the Counter Medications (Tylenol, Aspirin, etc.)
None
Other Medications
Home Remedies (list)
4. How do you feel about your weight now?
Too little
OK
Too much
5. How many times a day do you eat?
Meals
Snacks
6. How many times a week do you eat fast food or food from a restaurant?
Never
1-2 times
3-4 times
5 or more times
7. Are you on a special diet?
Yes
No
If yes, explain
8. Are there foods you limit or do not eat?
Yes
No
If yes, which ones?
9. What do you eat / drink on most days?
♦ Water
Coffee
Tea
Regular Soda
Diet Soda
Gatorade
♦ Juice
Punch / Kool Aid
Alcohol
Beer
Wine
♦ Fruits
Vegetables
♦ Milk (Skim / Lowfat / Whole)
Cheese
Yogurt
Cottage Cheese
Pudding / Custard
♦ Meat
Chicken
Turkey
Fish
Hotdogs
Tofu
Beans / Lentils
Peanut Butter Eggs Nuts
♦ Breads
Cereals
Tortillas
Rice
Noodles
Rolls
Crackers
Pan Dulce
♦ Candy
Cookies
Cakes
Donuts
Ice Cream
Chips
French Fries
♦ Other (list)
10. Which one or more of the following words describes how you feel?
Happy
OK
Tired
Depressed
Sad
Stressed
Angry
Other
11. What kind of activity do you do on most days?
Walk
Run
Bike
Dance
Sports
Swim
Exercise class / Gym
Garden
None
Other (list)
12. Do you ever run out of money or food stamps to buy food?
Yes
No
13. What nutrition and health questions do you have today?
For Staff Use Only
Date:
WIC Staff Name:
Participant WIC ID#:
Height:
Weight:
WIC is an Equal Opportunity Program
DHS (Eng) (09/05)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal