Child Nutrition Assessment Form
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Nutrition Assessment Form
Child’s Name:_______________________ Date of Birth:_______________________
Date:______________________________ Center:____________________________
1. What types of fluids does your child usually drink?
( Whole milk ( 2% Milk ( 1% Milk ( Juice
( Water ( Kool-Aid ( Other:_____________________
2. Does your child take vitamins? ( Yes ( No
3. Does your child have any known food allergies or is he/she on a special diet?
( If Yes, Pleas explain:_____________________________________________
( No
4. Are you concerned about your child’s weight?
( If Yes, please explain:____________________________________________
( No
5. Do you have any concerns about your child’s eating habits?
( If Yes, please explain:____________________________________________
( No
6. Is your child participating in WIC? ( Yes ( No
7. Does your child still drink from a bottle? ( Yes ( No
8. Meal time habits: Please check the following:
| |Always |Usually |Sometimes |Never |
|I expect my child to clean their plate. | | | | |
|Mealtime is a pleasant family time. | | | | |
|I limit the amount I let my child eat. | | | | |
|We sit together during mealtimes. | | | | |
|How often is the TV on during mealtime? | | | | |
|My child serves him/herself during meals. | | | | |
9. How many times a day does your child usually eat, including snacks?_______
What types of snacks does he/she eat most often?________________________
10. What are your child’s favorite foods?__________________________________
11. What are your child’s least favorite foods?_____________________________
12. Please estimate how often your child eats the following foods:
| |Never |Once |Several |Once |Two or |
| |Or |A |Times |A |More Times |
| |Rarely |Week |A week |Day |A Day |
|Dairy Products | | | | | |
|(cheese, yogurt, milk) | | | | | |
|Meat Products | | | | | |
|(beef, chicken, eggs) | | | | | |
|Other Protein | | | | | |
|(dried beans, eggs, peanut butter) | | | | | |
|Bread Products | | | | | |
|(bread, rice, pasta, cereal, tortillas) | | | | | |
|Fruit Products | | | | | |
|(bananas, oranges, apples, juice) | | | | | |
|Vegetable Products | | | | | |
|(corn, green beans, carrots) | | | | | |
|Sweets | | | | | |
|(cakes, cookies, candy, chips, soda) | | | | | |
|Fats | | | | | |
|(butter, oil, margarine, mayo) | | | | | |
13. Do you have any other concerns about your child’s growth or diet?
( If Yes, please explain:_____________________________________________
( No
Parent Signature:____________________________ Date:____________________
Reviewed 2012
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