Early Head Start Nutritional Assessment for Pregnant Moms
EARLY HEAD START PRENATAL NUTRITIONAL ASSESSMENT
Name:____________________________________ Date:___________________
1. Describe what your typical meals look like or write down what you ate yesterday for the following meals:
Breakfast:
Lunch:
Dinner:
Snack:
2. Do you consider your appetite to be: Good Fair Poor
3. How many times do you eat fast food in a week? ________
4. Who is responsible for the grocery shopping in your home?
5. How do you feel about your current weight and your weight gain during pregnancy?
6. What are some physical activities you like to do?
7. Are you taking a prescribed prenatal vitamin? Yes or No
8. Are you on the WIC program? Yes or No
9. When was your last dental visit? _______________
10. When was your last prenatal visit? _____________
11. What questions do you have about nutrition during your pregnancy?
6/10 To be completed w/in one month of enrollment p/head start/ehs/ehs expectant/prepostnatal
EARLY HEAD START POST NATAL ASSESSMENT
Name: _________________________________ Date: ___________________
Baby’s Name: ___________________________ DOB: __________________
1. What was your labor and delivery like?
2. Vaginal or C-section?
3. Any complications during delivery?
4. Was anyone with you during your delivery?
5. How are you feeling?
6. Are you breast-feeding or bottle-feeding?
7. Any concern with your baby’s feeding or appetite?
8. Health Department Nurse follow up appointment: ____________________________
9. When is your follow-up appointment with your Doctor/Midwife? _______________
10. When is your baby’s first well baby check? _________________________________
11. Is your baby receiving WIC? Yes or No
12. Are there any questions you have or resources you need?
6/10 To be completed at 1st home visit after delivery p/head start/ehs/ehs expectant/prepostnatal
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