Healthy Eating Questionnaire

Completing this food questionnaire and reviewing it with your physician or dietitian will help us make suggestions to improve your child’s diet. After completing this questionnaire, we recommend you keep a one- week food diary to double check what your child is eating and identify areas for improvement.

How often does your child eat:

  • Fruits? ______ times/day
    • What kinds of fruits does your child like?
    • Vegetables?_______ times/ day
      • What kinds of vegetables does your child like?
      • Whole grains? _______times/day
      • Fried foods such as French fries or fried chicken? ______ times/day or ______ times/ week
      • Snack foods such as potato chips or Cheetos? ______times/day or ______ times/ week
      • Sweet treats like candy, ice cream, or chocolate? ______ times/ day or ______times/ week

How much does your child drink in one day?

  • Soda or Coke:_____ cans a day of regular soda and ______ cans a day of diet soda
  • Milk: _____ ounces/ day or _____ cups/ day
  • Juice: ______ ounces/ day or _____ cups/day
  • Water: _______ ounces/day or ______ cups/day
  • Other ________: _______ounces/day or ______ cups/day

What does your child eat in a typical day?

Breakfast:

 

Snack:

 

Lunch:

 

Snack:

 

Dinner:

 

Dessert: