Toddler (6-24 months) Diet Questionnaire
Child's Name:
Child's Birth Date:
/ /
Today's Date:
/ /
1. Please check all of the following you have that work: Stove Top Oven Microwave Refrigerator
2. What does your child usually drink? (Please check all that apply)
Breastmilk Formula Cow's milk Goat's Milk
Sweetened Condensed Milk Evaporated Milk Soy Milk Water Juice/Juice Drinks
Regular Pop/Kool-Aid Sweetened Tea Herbal Teas Gatorade/Sports Drinks
Other:
3. From what does your child drink? (Please check all that apply)
Breast Bottle Sippy Cup Cup
4. Does your child ever walk around drinking from a sippy cup or a bottle?
No Yes
5 How is breastfeeding going?
Child not breastfed
a. How often does your child nurse in a 24-hour period?
b. Can you hear your child swallowing during feedings?
No
Yes
6. How many wet diapers does your child have in a 24-hour period?
7. How many dirty diapers does your child have in a 24-hour period?
8. Do you pump or express breastmilk for your child?
No Yes
a. How do you store breastmilk?
Refrigerator Freezer Other
b. How long do you keep breastmilk in the refrigerator before you throw it away?
hours
c. How long do you keep breastmilk after it's been thawed?
hours
9. Please check all items that might be in your child's bottle during a normal day.
Child does not take a bottle
Milk (including breastmilk) Formula Water Juice/Juice Drinks Cereal
Soda Pop/Kool-Aid/Sweetened Tea Corn Syrup Honey Baby Food
Other
a. What do you do with any milk or formula left in the bottle?
Leave it out to feed later Put back into the refrigerator for later Throw it away Other
b. How long do you let a bottle sit at room temperature?
hours
c. Is your child's bottle ever propped on a pillow, blanket, stuffed animal, etc.?
No Yes
10. What formula does your baby take?
with iron low iron Child does not take formula
a. What type of formula do you use?
Concentrate Powder Ready-to-feed
b. How do you mix the formula?
amount water
to
amount formula
What kind of water do you usually use to make the formula?
City/Rural Well Bottled Unsure
Do you ever add anything besides water to the formula?
No
Yes
, what?
c. Do you warm the formula?
No
Yes
, how?
d. How often does your child take formula during a normal day?
e. How much formula does your baby take at each feeding?
ounces
f. How do you store formula after you mix it?
Don't store; give to baby right away Refrigerator Freezer Other
g. How long do you keep mixed formula in the refrigerator before you throw it away?
days
h. How long does a can of formula last?
11. How many times does your child drink milk during a normal day?
Child does not drink milk
a. How much milk does your child drink each time?
ounces
b. What type of milk does your child usually drink?
Cow's
(
Whole (Vitamin D) Reduced/Low Fat (2%, 1% or 1/2%)
Skim
)
Lactose Free Goat's Evaporated Sweetened Condensed Soy Rice
Other:
c. Do you ever add flavoring to the milk?
No
Yes
12. How many times does your child drink water during a normal day?
Child does not drink water
a. How much water does your child drink each time?
ounces
b. What kind of water does your child usually drink?
City/Rural Well Bottled Unsure
c. Do you ever add anything to the water?
YesNo
, what?
OVER
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?
ounces
b) What kind of juice or juice drinks does your child usually drink?
c) Do you dilute the juice with water?
No Yes
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.
Baby foods
(
Cereal Fruits Vegetables Meats Dinners Desserts
)
Table foods
(
Mashed/blended Finely Chopped Coarsely chopped/sliced
)
Other:
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?
Meals Snacks
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
Other:
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)
Apples/Applesauce Bananas
Grapes
Oranges Pears Potatoes French Fries Corn Green Beans Carrots Sprouts Tomato
Other:
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
Tofu
Yogurt
Hard Cheese (American, Cheddar, Swiss...) Soft Cheese (Feta, Brie, Blue-Veined, Queso Fresco
Other:
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?
No Yes
, please list:
Was this problem diagnosed by a doctor?
No Yes
23. Please check and describe all of the following your child usually takes.
Over-the-counter drugs (laxatives, pain killers, etc.)
Prescription medication
Vitamin and/or mineral supplements
Herbs/Herbal Supplements (Eshinacea, ginger, etc.)
Other:
24. Do you worry about how much your child is eating?
No Yes
, 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?
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