Fit WIC Kids Nutrition Questionnaire

Participant
Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
ID#:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1.  Do you have any questions or concerns about your child's eating?

2.  How are meals with your child? (Pleasant, unpleasant)

What makes meals unpleasant? What do you do to try and make them more
pleasant?

3.  Who does your child usually eat with?
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

How often do the adults in your home eat with your child?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4.  Who decides when it is time to eat?
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Are these times about the same every day or do they vary?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

How many meals a day does your child eat? How many snacks?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

5.  Who usually decides what foods are served at a meal?
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Describe how you choose foods for a meal.

6.  Who usually decides when your child is finished eating?
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

How is this decided?

7.  What do you do if your child does not want to eat all or most of the
    food on his or her plate? What do you do if your child wants more of
    a food?

8.  What do you do if your child does not like one or more of the foods
    that are served?

9.  Does your child ever eat meals or snacks while watching TV? Yes No

10. Does your child take a bottle to bed at night? Yes No

Does he or she carry a bottle around during the day? Yes No

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| **1^st^ Visit**      | **2^nd^ Visit**        | **3^rd^ Visit**      |
|                      |                        |                      |
| Date:                | Date:                  | Date:                |
| \_                   | \_\_\_\_\_\_\_\_\_\_   | \_                   |
| \_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_ |                        | \_\_\_\_\_\_\_\_\_\_ |
|                      | Completed Question     |                      |
| Completed Question   | #s:\_\_\_\_\_\_\_      | Completed Question   |
| #s:\_\_\_\_\_\_\_    |                        | #s:\_\_\_\_\_\_\_    |
|                      | Goal:                  |                      |
| Goal:                |                        | Goal:                |
|                      | How to achieve goal:   |                      |
| How to achieve goal: |                        | How to achieve goal: |
|                      | Comments:              |                      |
| Comments:            |                        | Comments:            |
|                      | Plan for Next Visit:   |                      |
| Plan for Next Visit: |                        | Plan for Next Visit: |
|                      | CNW:                   |                      |
| CNW:                 | \_\_\_\_\_\_\_\_\_     | CNW:                 |
| \_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_ |                        | \_\_\_\_\_\_\_\_\_\_ |
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