WIC Nutrition Assessment for Women

1
Participant Name
First Name
Last Name
2
Are you following a special diet?
YESNO
3
What type of special diet?
Vegetarian
Vegan
Low calorie/weight loss
Macrobiotic
Food allergy
Low fat
Low Carbohydrate
4
If yes, is there a medical condition related to this diet?
YESNO
5
Do you routinely eat things that are non-food items?
YESNO
6
If yes, select all that apply.
Ashes
Baking Soda
Burnt Matches
Carpet Fibers
Chalk
Cigarettes or cigarette butts
Clay
Dust
Large quantities of ice and/or freezer frost
Paint chips
Soil
Starch (laundry or cornstarch)
7
On a typical day, how many times do you eat fruit?
5 or more
4
3
2
1
None
8
On a typical day, how many times do you eat vegetables?
5 or more
4
3
2
1
None
9
What type of milk do you drink?Select all that apply.
Milk (Cow)
Goat Milk
Rice Milk or Almond Milk
Soy Milk
Lactose Free Milk
None
10
What kind of milk do you drink?
Fat-free (skim)
Low-fat (1%)
Reduced fat (2%)
Whole
Not Applicable
11
On a typical day, how many times do you 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
12
On a typical day, how many times do you 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
13
On a typical day, how many times do you drink diet pop/soda and/or coffee/tea?
4 or more
3
2
1
None
14
On a typical day, how many times do you drink plain water?
4 or more
3
2
1
None
15
What kind of physical activities do you do on most days?Select all that apply.
None
Running
Housework/cleaning
Bike riding
Playing with my children
Walking
Swimming
Gardening/yard work
Gym
16
On a typical day, how many minutes do you spend doing these activities 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
17
Have you visited a dentist within the past 12 months?
YESNO
18
Do you have tooth decay, broken teeth, bleeding gums, missing teeth and/or misplaced teeth that make chewing difficult?
YESNO
19
Are you currently pregnant?
YESNO
20
Which of the following foods do you eat?Select all that apply.
Fresh squeezed fruit or vegetable juices
Unpasteurized (farm fresh) dairy products
Soft cheeses such as Feta, Brie, Camembert, Blue-veined cheese, Queso Blanco, Queso Fresco
Raw or undercooked meats, fish, chicken, turkey or eggs
Raw sprouts (alfalfa, clover, bean, radish)
Uncooked luncheon meats, deli meats, hot dogs
None of these
Should be Empty: