Completing this diet questionnaire and reviewing it with your physician or dietician will help us make suggestions to improve your child's diet. After completing this questionnaire, we recommend you keep a one-week diet diary for a "reality check" to see what your child is really eating.
How often does your child eat:
-
Fried foods such as hamburgers, french fries, or fried chicken? __ times a week
- Snack foods such as potato chips, tortilla chips, pretzels, Cheetos, etc? __ times a week
- Sweet treats like candy and chocolate? __ times a week
- Fruits and vegetables? ______ times a day
- What kinds of fruits does he/she like?
- What kinds of vegetables does he/she like?
How much does your child drink in a day?
- Soda pop: __ cans a day of regular soda
__ cans a day of diet soda
- Milk: ______ ounces a day
- Juice: ______ ounces a day
- Water: _______ ounces a day
- Other: _______ ounces a day
Last updated 05/31/10
