Healthy diet questionnaire

Suzanne Berman, M.D.

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

If you are having trouble answering these questions, you may not really know what your child is eating, and how much.

Last revised 12/20/00

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