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Form Hea 4450 - Wic Health History For Children 1-5 Years - Ohio Department Of Health Page 2

Check all that apply to your child.

Drinks from a cup

Drinks from a bottle

Goes to bed with a bottle or sippy cup

Walks around with a bottle or sippy cup

Is fed through a feeding tube

(36, 94)

What foods does your child refuse to eat?

None

(35)

Please check all the non-food items your child eats.

Printed paper

Paint chips

Dirt

Clay

Ice

Other _____________________________________________________________________________

None

(30)

Check all that apply.

Child feeds self

I run out of money or food stamps to buy food

Child has eating/chewing/swallowing problems

I have a working stove or microwave and refrigerator in my home.

Child usually does not eat at home

Child lives in a shelter, hotel or temporary place.

(37, 66, 93, 95)

What do you think about your child’s eating habits?

How many hours per day is your child physically active?

Less than one hour

One–two hours

Three or more hours

If anyone in your home smokes, where do they smoke?

Inside

Outside

Car

No one smokes

(46)

During the last six months, has your child been physically, verbally or sexually abused or neglected?

Yes

(67)

Do you have any questions or concerns?

Form Hea 4450 - Wic Health History For Children 1-5 Years - Ohio Department Of Health Page 2