Nutrition Questionnaire

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Dear Families:
As part of our early childhood grant program, we are required to have nutrition questionnaires completed on our prekindergarten students. This survey will provide us with nutrition information which will help inform state and local program guidelines pertaining to health, wellness, & nutrition. Thank you in advance for your participation.
Sincerely,
Pauline A Graef
Principal

Child's Name (First and Last) *

Today's Date *

YYYY

Classroom Teacher *

Frink

Knutson

Nye

New Student

Date of Birth

YYYY

WIC

Yes

Clear selection

SNAP

yes

Clear selection

Tell me about your child's appetite:

Does your child feed him/herself?

Yes

Clear selection

Has your child been iron deficient in the past year?

Yes

Clear selection

Describe what you do when your child doesn't eat what you've prepared:

List what your child eats for breakfast:

List what your child eats for lunch:

List what your child eats for dinner:

List what your child eats for snacks:

What food does your child especially like?

Are there foods your child dislikes? If so, what are they?

Please answer yes or no to the following

Yes

Does your child take vitamins?

Do the vitamins contain fluoride?

Are the vitamins prescribed?

Has there been any big changes in your child's appetite in the past month?

Does your child take a bottle?

Does your child have any problems swallowing or chewing?

Does your child have problems with diarrhea?

Does your child have problems with constipation?

Clear selection

Are there any foods that your child should not eat for medical, religious or personal reasons? If yes, please list.

Is your child on any special diet? If yes, what?

How many times a day does your child eat?

Milk, cheese, yogurt

Meath, poultry, fish, eggs, peanut butter, dried peas/beans

Bread, cereal, rice, grits, tortillas, crackers, muffins, bagels

Fruits and vegetables (including 100% juice)

Oil, butter, margarine, lard, fried foods

Cookies, Cakes, candy, gum, soda, fruit drinks (like Kool-Aid)

How many times a week does your child eat?

Carrots, broccoli, greens, winter squash, sweet potatoes

Tomatoes, oranges, grapefruits (fruit, sauce or juice)

Additional Information you would like us to know about your child's nutrition:

Name of person completing this form and relationship to child:

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