WIC Nutrition Assessment Ages 1-5

1
Child's Name
First Name
Last Name
2
Age (by month range)
12-23 Months
24-59 Months
3
Is your child following a special diet?
YESNO
4
What type of special diet?
Vegetarian
Vegan
Low calorie/weight loss
Macrobiotic
Food allergy
Tube feeding
Other
5
If yes, is there a medical condition related to this diet?
YESNO
6
Which of the following foods does your child eat?Select all that apply.
Fresh squeezed fruit or vegetable juices
Raw or undercooked meats, fish, chicken, turkey or eggs
Soft cheeses such as Feta, Brie, Camembert, Blue-veined cheese, Queso Blanco, Queso Fresco
Uncooked luncheon meats, deli meats, hot dogs
Unpasteurized (farm fresh) dairy products
Raw sprouts (alfalfa, clover, bean, radish)
None of the Above
7
Does your child routinely eat things that are non-food items?
YESNO
8
If yes, select all that apply.
Ashes
Carpet Fibers
Cigarettes or cigarette butts
Clay
Dust
Foam Rubber
Paint chips
Paper
Soil
Starch (laundry or cornstarch)
Other
9
On a typical day, how many times does your child eat fruit?
5 or more
4
3
2
1
None
10
On a typical day, how many times does your child eat vegetables?
5 or more
4
3
2
1
None
11
What type of milk does your child drink?Select all that apply.
Breastmilk
Formula
Milk (Cow)
Goat Milk
Rice Milk or Almond Milk
Soy Milk
Lactose Free Milk
None
Other
12
Name of Formula
13
What kind of milk does your child drink?
Fat-free (skim)
Low-fat (1%)
Reduced fat (2%)
Whole
Not Applicable
14
On a typical day, how many times does your child drink milk?
4 cups or more/Many times per day
3 cups/Three times per day
2 cups/Twice per day
1 cup or less/Once per day or less
15
On a typical day, how many times does your child drink juice, fruit/sports drink, regular pop/soda, sweet tea and/or water with Kool-Aid or sugar?
4 or more
3
2
1
None
16
On a typical day, how many times does your child drink diet pop/soda and/or coffee/tea?
4 or more
3
2
1
None
17
On a typical day, how many times does your child drink plain water?
4 or more
3
2
1
None
18
What is your child's water source?Select all that apply
City/County water system
Rural water system
Private well
Bottled Water
19
Does your child drink any beverages, other than water from a baby bottle or sippy cup?
YESNO
20
When does your child drink beverages, other than water from a bottle/sippy cup?Select all that apply
In bed at night
At naptime
At meals and snacks
Carries a bottle/sippy cup around during the day
21
Does your child take any vitamins, minerals, herbs or herbal supplements?
YESNO
22
Is yes, select all that apply.
Children's multivitamin
Iron supplement
Fluoride supplement
Herbal supplement
Vitamin D
Other
23
On a typical day, how many hours is your child in front of a screen? (TV, computer, video game, cell phone)
None
Less than 1 hour
1 hour
2 hours
3 hours
4 hours
5 or more hours
Unknown
24
On a typical day, how many hours is your child in active play/exercise? (breathing harder or sweating)
Less than 15 minutes
15 minutes
30 minutes
45 minutes
60 minutes (1 hour)
90 minutes (1.5 hours) or more
Not applicable
25
Has your child visited a dentist within the past 12 months?
YESNO
26
Does your child have tooth decay (including baby bottle tooth decay), broken teeth, bleeding gums, missing teeth and/or misplaced teeth that make chewing difficult?
YESNO
27
Does your child brush their teeth with toothpaste that has fluoride?
Yes
No
Don't know
Should be Empty: