13. How many times does your child drink juice during a normal day?
Child does not drink juice
a) How much juice does your child drink each time?
b) What kind of juice or juice drinks does your child usually drink?
c) Do you dilute the juice with water?
14. When did your child start eating something other then breastmilk or formula?
Hasn't Started Yet 0-3 months 4-6 months
After 7 months
a. What types of food does your child eat? Please check all that apply.
Cereal Fruits Vegetables Meats Dinners Desserts
Mashed/blended Finely Chopped Coarsely chopped/sliced
b. At mealtimes, how often does your child eat the same foods as the rest of the family?
Most of the time Sometimes Rarely
, what does your child eat?
c. How is your child fed these foods? Please check all that apply.
Bottle Spoon Fingers/Self-feeding
d. Can your child feed him/herself? No Yes
15. How many times does your child eat on a normal day?
16. Please mark the situations that describe where your child normally eats. (Check all that apply)
In a bed/crib In caregiver's arms/lap In a car seat In a high chair At a table On the sofa At home
In a restaurant/fast food In the car At childcare/Head Start/preschool With the TV on With family/friends Alone
17. 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 Honey Graham Crackers Cereal/Cereal Bars Nuts Chips
Hard Candies Popcorn Pretzels Crackers Ice Cream Other:
18. 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)
Oranges Pears Potatoes French Fries Corn Green Beans Carrots Sprouts Tomato
19. 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
20. 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:
21. Does your child regularly eat anything that is not food, such as dirt, paper, crayons, pet food or paint chips? No Yes
22. Does your child have health/medical/dental problems?
, please list:
Was this problem diagnosed by a doctor?
23. 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.)
24. Do you worry about how much your child is eating?
, please explain:
25. What is one thing you like about your child's eating?
26. What is one thing that you would like to change about your child's eating?