10/2012
Prenatal Diet Questionnaire
Your Name: _____________________________________________________ Birth Date: ___/___/_____ Today’s date: ___/___/_____
1. Please check all of the following you have that work. Stove Top Oven Microwave Refrigerator
2. How many times do you eat each day? Meals _____ Snacks _____
3. Are there any foods or beverages that you cannot or will not eat? No Yes, please list ____________________________________
4. Are there any foods of which you think you do not eat enough? No Yes, please list ____________________________________
5. What do you usually drink? (Please check all that apply.) Milk Water Juice/Juice Drinks
Gatorade/Sports Drinks Wine/Beer/Alcoholic Drinks Coffee/Tea Herbal Teas Hot chocolate
Regular Pop/Kool-Aid Diet Pop Other: _________________________________________________________
6. How often do you drink milk? Several times/day Once/day Less than once/day Do not drink milk
What type of milk do you usually drink? Cow’s (_____Whole (Vitamin D) _____Reduced/Low Fat (2%, 1% or ½%) _____Skim)
Lactose Free Evaporated Sweetened Condensed Soy Rice Goat’s
Raw (Cow’s or Goat’s) Other: _________________________________________________________________
7. How many times do you eat fruits and vegetables during a normal day? ________________ Do not eat any fruits or vegetables
Which fruits and/or vegetables (not juice) do you usually eat? (Please check all that apply.) Bananas Grapes
Apples/Applesauce Oranges Pears Carrots Green Beans Potatoes French Fries
Corn Sprouts Tomato Other: ________________________________________________________________________
8. How many times do you eat protein foods during a normal day? ____________ Do not eat protein foods
9. Which protein foods do you usually eat? (Please check all that apply.) Beef/Buffalo Chicken/Turkey Fish/Seafood
Pork/Lamb Hot Dogs/Lunch Meat Meat Spreads/Pâté Dried/Canned Beans Eggs Tofu Yogurt
Soft Cheese (Feta, Brie, Blue-Veined, and Queso Fresco) Hard Cheese (American, Cheddar, Swiss…)
Other ________________________________________________________________________________________________
10. Do you ever eat anything that is not food, such as ashes, chalk, clay, dirt, large quantities of ice, or starch (laundry/cornstarch)? No Yes
11. Are you on a special diet? No Yes, please describe _____________________________________________________________
12. How much weight do you think you should gain with this pregnancy? ________________ pounds
13. Have you seen a doctor for this pregnancy? No Yes, date of your first visit? ___/___/______ # of visits ______________
14. Are you expecting twins, triplets, etc? No Yes
15. Are you having any problems/complications with this pregnancy? Heartburn Nausea and vomiting Gestational diabetes
High blood pressure Constipation Diarrhea Weight loss Other, please describe __________________
16. Do you have any medical/health/dental problems? No Yes, please list ___________________________________________
Was this problem diagnosed by a doctor / dentist? No Yes
17. Please check and describe all of the following you routinely use. (All information given to the WIC Program is confidential.)
Over-the-counter drugs (laxatives, pain killers, etc.) _____________________________________________________________
Prescription medication ______________________________________________________________________________________
Vitamin and/or minerals supplements ___________________________________________________________________________
Herbs/Herbal Supplements (Echinacea, ginger, etc.) _____________________________________________________________
Tobacco Street drugs (Marijuana, cocaine, methamphetamines, etc.) Other: ____________________________________
18. Have you had a blood lead test? No Unsure Yes, where? _______________________________________________
19. Not including this time, how many times have you been pregnant? ________________ (If this is your first pregnancy stop here)
When did your last pregnancy end? ___/___/______
Are you currently breastfeeding a baby/child? No Yes
Please check any of the following that were true with any of your previous pregnancies.
My baby was born more than 3 weeks early My baby was born weighing less than 5 pounds 9 ounces
My baby was born weighing 9 pounds or more My baby was born with a birth defect
My doctor told me I had gestational diabetes I have had no complications
Other, please list ___________________________________________________________________________________________
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