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
- 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:
Activity (list any activities today and how long you did them):
