Pathfinder Kids Kampus

Nutrition Questionnaire

Child’s Name: / Date of Birth: / Date Completed:

A)  Background Information

Is/was child: / Breast-fed Bottle-fed / Does s/he currently take a bottle? Y N
Other: / If yes, how often?
At what age (in months) did child first: / eat solid foods? / drink from a cup? / feed self?
Do you have any concerns about what your child eats? / Y N / If yes, what?

B)  Child’s Nutritional Needs

Please check any of the following that are true for your child, then explain in the space below:
Child takes vitamin/mineral supplements Y N / Child eats or chews things that aren’t food Y N
Supplements contain iron or fluoride Y N / Child has trouble chewing or swallowing Y N
Supplements were prescribed Y N / Child often has diarrhea or constipation Y N
Please check one of the boxes below regarding your child’s diet:
r  This child does not have a food allergy, medical need for dietary restriction, religious or ethnic food preference. / r  This child requires a food/dietary restriction. Based on a known medical condition, food allergies, religious or ethnic food preference, please eliminate the following from my child’s diet/menu: . I understand that this exemption requires a Food Substitution Form or other written documentation from a doctor or religious leader.

C)  Child’s Eating Habits / Usual Food Group Eating Frequency

About how often does your child eat a food from each of the following food groups
(please check in appropriate box) / Almost never (less than once per week) / Sometimes (2-4 times a week) / Almost every day (6-7 times a week) / More than once a day (7+ times a week)
Milk, cheese, yogurt
Rice, grits, bread, cereal, tortillas
Green vegetables, carrots, broccoli, winter squash, pumpkin, sweet potatoes
Oranges, grapefruit, tomatoes, fruit/juice
Oil, butter, margarine, lard
Cakes, cookies, sodas, fruit drinks, candy
What did child eat and drink in the last 24 hours?
List all foods and beverages consumed as meals or snacks.
For mixed dishes, list main ingredients separately. / Amount eaten / Breads & cereal / Fruits / Vegetables / Meats / Milk / Other
Morning:
Midmorning:
Noon:
Afternoon:
Evening:
Before Bed:

Signature of Parent/Guardian: Date:

Reviewed by Nutritionist Name: Initial: Date: