Children’s Nutrition Questionnaire - Harvard University

Name:ID:Date//DOB://Age:Respondent: (please check)MotherOtherGC 5/03 Copyright 1993, Harvard School of Public HealthContinued on next page1 Children s Nutrition QuestionnaireWhat Have You Been Eating Lately? During the past 4 weeks, how often did you eata serving of each of the foods listed here? Mark only one X for each foodExample:What kind of milk does your child usually drink? (Check one)1breastmilk3whole51%7 Chocolate Milk2formula42%6skim8otherlast 4weekseach weekeach dayNumber of times01 312 4 5 6 1 2 3 4 5 6+Milk Hot chocolateXX01 23456 78last 4weekseach weekeach dayNumber of times01 312 4 5 612 3 4 56+MilkHot chocolateCheese, plain or in sandwichesYogurtIce cream (cones, sandwiches, sundaes)Pudding01 23456 78last 4weekseach weekeach dayNumber of times01 312 4 5 612 3 4 56+Orange juice or grapefruit juiceOther juiceFruit drinks (Hi-C, Kool-aid, lemonade, sportsdrink)

4. Does your child take a multi-vitamin pill (Flintstones, TriViFlor): no yes 01 If yes, how often: Every day 4–6 times a week 1–3 times a week Less than one time a week 12 3 4 5. Does your child take a separate iron pill (not in the multi-vitamin pill above): no yes 01 6.

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