12) Which snack foods does your child usually eat? (Please check all that apply) Child does not eat snack foods
Fruit Fruit Snacks Cookies/Snack Cakes Crackers Chips Popcorn Nuts Pretzels
Ice Cream Cereal/Cereal Bars Hard Candies Other:
13) How many times does your child eat fruits and vegetables (not juice)during a normal day?
Child does not eat fruits and vegetables
Which fruits and/or vegetables (not juice) do you usually eat? (Please check all that apply)
Apples/Applesauce Bananas Grapes
Oranges Pears Potatoes French Fries Corn Green Beans Carrots
14) How many times does your child eat protein foods during a normal day?
Child does not eat protein foods
Which protein foods does your child usually eat? (Please check all that apply)
Beef/Buffalo Chicken/Turkey Fish/Seafood
Pork/Lamb Hot Dogs/Lunch Meat Dried Beans Peanut Butter Eggs
Hard Cheese (American, Cheddar, Swiss...) Soft Cheese (Feta, Brie, Blue-Veined, Queso Fresco
15) Which sweets does your child usually eat? (Please check all that apply) Child does not take anything sweet
Sugar Honey Syrup Candy Other:
How are they usually eaten? (Please check all that apply)
Add to/in drinks In pre-sweetened drinks On the pacifier Added to/on foods
In sweet foods (candies, cookies, cakes, etc. Other:
16) Does your child regularly eat anything that is not food, such as dirt, paper, crayons, pet food or paint chips? No Yes
17) Does your child have health/medical/dental problems?
, please list:
Was this problem diagnosed by a doctor?
18) Please check and describe all of the following your child usually takes.
Over-the-counter drugs (laxatives, pain killers, etc.)
Vitamin and/or mineral supplements
Herbs/Herbal Supplements (Eshinacea, ginger, etc.)
19) Do you worry about how much your child is eating?
, please explain:
20) Has your child had a blood lead test?
No Yes Unsure
21) What is one thing you like about your child's eating?
22) What is one thing that you would like to change about your child's eating?
If yes, where?
What were the results?
23) How much time does your child spend actively playing each day?
24) About how many hours does your child sit and watch TV, videos or DVDs on a normal day?
Child does not usually watch any TV, videos or DVDs