MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES WIC AND NUTRITION SERVICES

PARTICIPANT NAME AND DCN

NUTRITION ASSESSMENT FOR CHILDREN AGES 1-5

DATE OF BIRTH

AGE:

Form completed by:

Please think about your childs eating pattern and answer the following questions to the best of your ability. Place a check mark in the box and/or write-in your answer.

Nutritionist

12-23

MONTH RANGE

WIC Certifier

24-59

DATE COMPLETED

CAREGIVER 1. How would you describe your childs appetite? Good Fair Poor 2. Have you noticed any recent changes in your childs appetite? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. 4. Do you have any questions about your childs eating habits? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If yes, what are they? What do you do when your child does not want to eat or only wants to eat a certain kind of food?

Yes

Yes

No

No

5.

6.

Does your child frequently choke or gag on food? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If yes, list: How are most foods your child eats prepared? Check all that apply. [425.4 428 Mashed Pureed or Baby foods Chopped Liquid Finger foods Other: 381]

Yes

No

9.

13. How are most foods prepared? Check all that apply. Baked Fried Boiled Roasted

At mealtimes, how often does your child eat the same foods as the rest of the family? (Check one) Most of the time Sometimes Rarely If rarely, what does your child eat? List: 10. How many days a week does your child eat at a childcare setting (including Head Start)? _____ days/week 11. In a typical week, how many meals does your child eat from a restaurant, including fast food? _____ meals/week _____ meals/day 12. In a day, how many meals or snacks are eaten in front of the TV? _____ snacks/day EATING PATTERN 14. Are there any foods that you think your child isnt eating enough of? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes If yes, check all that apply. Milk, yogurt, cheese Meat, fish, eggs, beans Fruits Vegetables Bread, cereal, rice and pasta 15. Are there any foods that you think your child is eating too much of? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If yes, list: 16. Does your child frequently eat sweet foods like lollipops, candy, sweetened cereals, or desserts? . . . . . . . . . . . . . . . . If yes, list Item(s) & Amount(s): Broiled Grilled Microwaved No No No No No No No No No

MEAL PATTERN _____ meals/day _____ snacks/day 7. How many times a day does your child eat? What type foods does your child typically snack on? Check all that apply. Milk, yogurt, cheese Meat, fish, eggs, beans Fruits or vegetables Bread, cereal, rice and pasta Chips/salty foods cookies/cakes/sugary foods _____ days/week 8. How many days in a week does your family usually eat a meal together?

Other:

Yes

*17. Does your child eat foods such as: [425.5] a. unpasteurized fruit or vegetable juices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. unpasteurized dairy products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c. soft cheeses such as Feta, Brie, Camembert, blue-veined cheese, Mexican-style cheese . . . . . . . . . . . . . . . . . . . . d. raw or undercooked meats, fish, chicken, turkey or eggs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e. raw vegetable sprouts (alfalfa, clover, bean, radish) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . f. uncooked luncheon meats, deli meats, hot dogs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . *18. Does your child routinely eat things that are non-food items? [425.9] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If yes, check all that apply. Ashes Clay Paint chips Carpet fibers Dust Soil Cigarette or cigarette butts Foam rubber Starch (laundry or cornstarch) Paper Other:
NUTRITION ASSESSMENT FOR CHILDREN AGES 1-5 (TURN PAGE OVER TO COMPLETE) PAGE 1 OF 2

Yes Yes Yes Yes Yes Yes Yes

Yes

No

MO 580-2798 (11-10)

WIC-35

Yes No 19. Does your child feed himself/herself [425.4 428] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If yes, check all that apply. Eats with fingers Uses a fork/spoon Drinks from a sippy cup Drinks from a regular cup or glass Other: *20. Is your child following a special diet? [341-362] [425.6] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No If yes, check: Vegetarian Vegan Food allergy or intolerance Low calorie/weight loss Macrobiotic Other: 21. Are you breastfeeding this child? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No If yes, how often? BEVERAGES 22. Does your child drink milk? [425.1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No If yes, check all that apply. Formula (name) ___________________________________ Low-fat (1%) Reduced fat (2%) Whole Rice Milk or Soy Milk Fortified Fat-free (skim) Rice Milk or Soy Milk Unfortified Powdered Milk Evaporated Milk Sweetened Condensed Milk Goats Milk Other: 23. How often does your child drink milk? (Check one) Many times/day (More than 3 cups) Several times/day (3 cups) Once/day (1 cup) Less than once/day *24. What other beverages does your child drink in a typical day? Check all that apply. [425.2] Juice (100%) Water plain Water - sugar added Sports drinks Regular pop/soda Diet pop/soda Gelatin Water/Kool-Aid Other: 25. How often does your child drink 100% fruit juice? Many times/day (More than 3 cups) Several times/day (3 cups) 26. What is your childs main source of water? (Check one) Fruit drinks Coffee/tea

BABY BOTTLE AND SIPPY CUPS 27. Does your child drink from a baby bottle? [425.3] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28. What is usually fed in the bottle? Check all that apply. [425.3] Milk Juice Water Fruit drinks Sports drinks Pop/soda Coffee/tea Cereal/other solid foods added to bottle Other: 29. Does your child take the bottle or sippy cup to bed at night or naptime? [425.3] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30. Does your child carry around a bottle or sippy cup during the day? [425.3] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SUPPLEMENTS

City water system Rural water system Private well Bottled water a. If private well, has it been tested for bacteria or nitrates? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a. If yes, check results: Safe Unsafe Dont know b. Do you know if your water is fluoridated? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c. Does your child brush his teeth with toothpaste that has fluoride? . . . . . . . . . . . . . . . . . . . . . . . .

Once/day (1 cup) Yes

Less than once/day No Dont know

Yes Yes

No No

Yes

Dont know Dont know

No No No

31. Does your child take any vitamins, minerals, herbs or herbal supplements? [425.7 425.8] . . . . . . . . . . . . . . . . . . . . Yes No If yes, check type: Childrens multivitamin Iron Supplement Fluoride supplement Herbal supplement Vitamin D Other: FOOD SECURITY AND PROGRAM PARTICIPATION 32. In the past month, did you or anyone in your household ever eat less than you felt you/they should or not eat for a whole day because there wasnt enough money for food? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No Dont know or refused 33. Is your child enrolled in Early Head Start, Head Start or Parents as Teachers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 34. Does your family participate in any food or nutrition programs?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No If yes, check all that apply. Food Stamps School lunch Family Nutrition Education Program (FNEP) Commodity program Food Pantry Other: 35. Do you have adequate equipment for food storage and preparation such as a refrigerator, a stove that works, and storage free from pests and harmful chemicals?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No PHYSICAL ACTIVITY 36. In a typical day, how many hours does your child watch TV, play video games and/or play computer games? Less than 1 hour 1-2 hours More than 2 hours 37. In a typical day, how many hours does your child play outside? Less than 1 hour 1-2 hours More than 2 hours TO BE COMPLETED BY WIC OFFICE PERSONNEL ONLY
SIGNATURE (RISK ASSESSMENT) DATE MO 580-2798 (11-10) TITLE SIGNATURE (NUTRITION COUNSELING) DATE TITLE PAGE 2 OF 2 WIC-35

Yes Yes

NUTRITION ASSESSMENT FOR CHILDREN AGES 1-5 THIS INSTITUTION IS AN EQUAL OPPORTUNITY PROVIDER