Child Nutritional Assessment - DOC - DOC by 4d94nw


									                                                  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:
      This child does not have           This child requires a food/dietary restriction. Based on a known medical
       a food allergy, medical             condition, food allergies, religious or ethnic food preference, please eliminate
       need for dietary                    the following from my child’s diet/menu:
       restriction, religious or                                                                                          .
       ethnic food preference.             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            Almost
                                                                                               never (less        Sometimes        Almost             More than
                      (please check in appropriate box)                                        than once
                                                                                                                  (2-4 times a
                                                                                                                                   every day
                                                                                                                                   (6-7 times a
                                                                                                                                                      once a day
                                                                                                                                                      (7+ times a
                                                                                               per week)                           week)              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?
                                                                                                       & cereal




 List all foods and beverages consumed as meals or snacks.                          Amount

 For mixed dishes, list main ingredients separately.                                eaten





 Before Bed:

 Signature of Parent/Guardian:                                                                                                    Date:

 REVIEWED BY NUTRITIONIST Name:                                                     Initial:                                     Date:

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