Children’s Nutrition Questionnaire

1 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)

2 BananaPeachesFruit cocktail, mixed fruitOrange or grapefruitApple or pearApplesauceGrapesStrawberriesMelonPin eappleRaisins or prunesGC 5/03 Copyright 1993, Harvard School of Public Health012345678 Number of times4-52-315-62-411-30last 4weekseach dayeach week6+012345678each dayeach weeklast 4weeks4-52-315-62-411-306+Number of timesMark only one Xfor each often did you eat a serving of these foods during the past 4 weeks?2 CornPeas Tomatoes, tomato sauce, salsaPeppers (green, red or hot)CarrotsBroccoliGreen beansSpinachGreens (mustard, turnip, kale)Mixed vegetablesSquash, orange or winterZucchini, yellow squashFrench fries, fried potatoes, tater totsPotatoes (baked, boiled, or mashed)Sweet potatoes or yamsCabbage, coleslaw or cauliflowerLettuce saladSalad dressingMayonnaiseChips (potato, corn or others)Popcorn or pretzelsCrackersNutsCookies or browniesCake or cupcakePieJelloChocolate or candy barOther candy (not chocolate)Coffee or teaSoda, soft drink, pop (not sugar free)

3 Soda, soft drink, pop (sugar free)GC 5/03 Copyright 1993, Harvard School of Public Health01 2 3 4 5 6 7 84-52-315-62-411-306+Number of timeslast 4weekseach dayeach week1-302-34-56+15-62-41 Number of timeslast 4weekseach dayeach week01 2 3 4 5 6 7 83 Beans (baked, chili, or other)RiceSpaghetti or other pastaPizzaTacos, burritosMacaroni and cheeseHot dogsSausageHamburger (prepared any way)Canned tunaFried fish, fish sticksOther fishCold cuts (baloney, ham, salami)Fried chicken, chicken nuggetsOther chicken or turkeyPork or hamRoast beef or steak Liver, organ meatsPeanut butterBread (slice) toast, roll, or pitaButter (not margarine)MargarineVegetable soupOther soupCornbread or tortillaEggsBaconHot cereal, gritsCold cerealDonutSweet roll or muffinPancake, waffle, or french toastEnglish muffin or bagelBiscuit1.

4 What type of bread does your child usually eat:white breadwhole wheat or dark breadabout half and halfDON T EAT BREAD12342. What type of margarine does your child usually use:sticktubsqueezeDON T USE MARGARINE12 34Is this margarine:corn oilnonfatother12 33. If your child eats cold breakfast cereal, what type:high fiber (eg. All Bran)unsweetened (eg. Corn Flakes)sweetened (eg. Cap n Crunch)1234. Does your child take a multi-vitamin pill (Flintstones, TriViFlor): noyes01If yes, how often:Every day4 6 times a week1 3 times a weekLess than one time a week12345. Does your child take a separate iron pill (not in the multi-vitamin pill above): noyes016.

5 Does your child take a separate fluoride supplement (not in the multi-vitamin pill above): noyes017. Does your child eat fried food at home: noyes01If yes, how often:Every day4 6 times a week1 3 times a weekLess than one time a week1234If yes, what type of fat do you use to fry at home:buttermargarinecriscocorn oilcanola oilolive oilother vegetable oil12345678. Do you bake cookies, cake or pies at home: noyes01If yes, how often does your child eat home-baked cookies, cake or pies?Every day4 6 times a week1 3 times a weekLess than one time a week1234If yes, what type of fat do you use to bake at home:buttermargarinecriscocorn oilcanola oilolive oilother vegetable oil1234567GC 5/034