Child's Name: Child’s date of birth:
Caregiver’s Name: Relationship to Child:
Ch ild’s most recent Height/Weight and approximate date of measurements:
Child’s Birth Weight and Length
Please answer the following questions about your child's dietary habits. Only answer those questions that apply.
1. What are your concerns about your baby’s/child’s nutrition?
2. Does your child have any chronic illness or medical condition?  YES  NO If yes, please list:
3. Was your baby/child premature?  YES  NO If yes, how many weeks?
4. Has your baby/child seen a registered dietitian before?  YES  NO If yes, where?
5. Does your baby/child have any food allergies?  YES  NO If yes, please list:
6. What reaction does your child have when these foods are eaten?
How would you categorize it?  mild  moderate  severe  life threatening
7. Was your child ever on a special diet?  YES  NO If yes, who recommended the diet?
8. Are there any food practices related to cultural/ethnic/religious beliefs?  YES  NO
9. Does your baby/child drink: (indicate by a checkmark all that apply and estimate amount per 24 hours)
 breastmilk  whole cow’s milk

 Pediasure or similar product
 infant formula
Instant breakfast
 2% milk
 skim milk _____________________________
 go at’s milk
 water  soft drinks
 tea
 other:
 juice
Please note: All information provided by you on this document and in sessions is strictly confidential.

10. Was your baby/child ever breastfed?  YES  NO
11. If you are currently breastfeeding, do you have any concerns? If yes, please specify:
12. If your baby/child is on formula, list all formulas used:
13. If your baby/child is on formula, how is it prepared?
 follow directions on can
 add more water than directions call for
Are other supplements added?
 cereal  sodium
 polycose  potassium
 add less water than directions call for  oil/microlipid  other
14. If your baby/child is on formula, is the formula iron fortified?  YES  NO If no, why not?
15. If your baby/child is on formula, how many cans of formula do you use each week?
16.
__ powdered _____ liquid concentrate
Is your child enrolled on the WIC Program?  YES
_____ ready to feed liquid
 NO If yes, where?
If yes, do you ever have to buy formula?  YES  NO If yes, how many cans each month?
17. Does your baby/child take vitamin or mineral supplements?
 vitamins  multivitamin with minerals  iron  fluoride  herbal products  other
18. Does your baby/child take a bottle to bed?  YES  NO If yes, what is in the bottle?
19. Do you add solid foods to the bottle?  YES  NO
20. Sleep/wake cycle: (circle hours when your baby/child is usually awake)
12 mid 1 2 3 4 5 6 7 8 9 10 11 12 noon 1 2 3 4 5 6 7 8 9 10 11
21. At what times does your baby/child eat?
12 mid 1 2 3 4 5 6 7 8 9 10 11 12 noon 1 2 3 4 5 6 7 8 9 10 11
22. Does your child eat at approximately the same time every day?  YES  NO
23. In what position is your baby/child during feedings? 
l ap/cradles in arms  infant seat  walker
 laying flat on back  high chair  regular chair  other:
24. How does your baby/child eat? (circle all that apply) breast bottle spout cup open cup spoon fork infant feeder fingers straw special feeding equipment feeding tube
25. How does your baby/child act during the feeding?  happy/eager  concentrates on eating  fussy
 easily distracted  tires easily  sleepy/tired  trouble breathing while eating  must be burped frequently  frequently gags/coughs/chokes
26. Do any of the following apply to your child at his/her present age? (check all that apply)
 7 mo of age or older and has not started using a cup yet
 9 mo of age or older and does not finger feed yet
 12 mo of age or older and drinks liquids primarily from the bottle
 19 mo of age or older and does not use a spoon yet
Please note: All information provided by you on this document and in sessions is strictly confidential.

27. If your child is older than 12 mo of age, does he/she avoid or reject any of the following food groups? (mark all that apply)  grains (cereal, bread, rice, pasta)  fruits  vegetables  dairy (milk, cheese, yogurt)
 protein sources (meat, eggs, dried beans and peas)  fats (butter, salad dressings, oils)
28. Does your baby/child prefer foods at a certain temperature?  YES  NO
29. Does your baby/child regularly eat: (check all that apply)
Strained/pureed/baby foods:  cereal  juice  fruit  vegetable  meat  dinners  egg yolk
Table foods:  cereal  bread  pasta  juice  fruit  vegetables  meat
 poultry  fish  beans/peas  peanut butter  cheese
30. How often does your baby/child eat? Every hours; times per day; meals; snacks
31. How long does it take your baby/child to finish a meal?  < 30 minutes  30-45 minutes  >45 minutes
32.
33.
At what age did you begin solid foods?
Describe your child’s appetite:  good
. What was the first food?
 fair  poor
34. How do you know your baby/child is hungry? (check all that apply)  awakens  sucks on hand/fingers
 fussy  cries  screams  says words that mean food  points
35. How do you know your baby/child is full? (check all that apply)  stops eating  falls asleep
 spits out food or nipple  turns away from food  plays with food or is easily distracted
36. Does your baby/child do anything that upsets you at mealtimes such as refusing to eat, excessive throwing of food or utensils or other? Please explain:
37. What describes your baby’s/child’s usual feeding behavior?
 seems to enjoy eating, takes feedings easily, good appetite
 happy at beginning of feeding, then often gets fussy or distressed during feedings
 frequently has trouble breathing while eating
 often does not wake for feeding, tires easily with feedings, or often has difficulty finishing feedings
 eats slowly, usually takes more than 30 minutes (infants)/45 minutes (toddler) to eat (excluding time for diaper changes, play, etc.)
 usually has difficulty sucking, swallowing or chewing
 frequently gags, coughs, or chokes during feedings
 refuses to eat, is difficult to feed, fussy throughout most of feeding, arches backward, or doesn’t seem to enjoy eating
 picky eater, seems to eat very little, not interested in food or eating, or has poor appetite
38. Does your baby/child experience any of the following?  difficulty with sucking  difficulty with swallowing
 difficulty with chewing  spit up or vomiting  gagging  diarrhea  constipation
39. Usual stool frequency:
40. Does your baby/child take any medicines other than vitamin or mineral supplements?  YES  NO
If yes, please list:
42. What meal(s) does your child usually skip?
41. How many meals does your child skip?
 5-10 meals per week  Less than 5 meals per week  1-2 meals per week  None
Please note: All information provided by you on this document and in sessions is strictly confidential.

43. What are some of your child’s favorite foods?
44. Does your child eat clay, paint chips, or anything not usually considered food?  YES  NO
If yes, what? How often?
45.
Where does your child eat most of their meals?  high chair  kitchen table  living room
 on the run  in front of the TV  school/daycare  other:
46. Please list any additional concerns or questions you would like addressed
____________________________________________________________________________________
Please note: All information provided by you on this document and in sessions is strictly confidential.