Child Nutrition Assessment

Child Nutrition Assessment Child’s Name:

Date of birth:

Name of person completing form:

Relationship to child:

Head Start Center:

What foods does your child especially like? What foods does your child dislike? How would you describe your child’s eating?

☐ Good

Does your child eat other things than food?

☐ Yes

☐ Picky

☐ Too much

☐ Too little

☐ No Explain:

Does your child take vitamin/mineral supplements? ☐ Yes If yes, do they contain: ☐ Iron ☐ Flouride

☐ No If yes, what kind?:

Does your child have trouble chewing or swallowing? ☐ Yes

☐ No Explain:

Do you consider your family’s nutrition habits to be healthy? ☐ Yes What does your child eat on most days? (check all that apply):

☐ No Explain:

☐ Grains ☐ Vegetables ☐ Fruit

☐ Meat/beans ☐ Milk or milk products ☐ Sweets ☐ Fats (oil, butter) What does your child drink on most days? (check all that apply): ☐ Juice ☐ Soda ☐ Kool-aid ☐ Whole milk

☐Low fat milk

☐ Sports drink

Do you consider your child to be physically active?

☐ Water ☐ Yes

☐ Other ☐ No Explain:

Have you or your doctor ever had concerns about your child’s weight? ☐ Yes

☐ No

If you answer Yes to the following questions, additional paperwork must be completed Are there any foods your child does not eat due to religious, cultural, or medical reasons? ☐ Yes ☐ No Explain:

Does your child have food allergies or a special diet prescribed by a Health Care Provider? ☐ Yes ☐ No Explain: Head Start Personnel:

2017-2018

Date: