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WIC Nutrition Assessment for Women
Missouri Department of Health & Senior Services | WIC & Nutrition Services
20
Questions
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Spanish (Latin America)
1
Participant Name
First Name
Last Name
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2
Are you following a special diet?
YES
NO
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3
What type of special diet?
Vegetarian
Vegan
Low calorie/weight loss
Macrobiotic
Food allergy
Low fat
Low Carbohydrate
Other
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4
If yes, is there a medical condition related to this diet?
YES
NO
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5
Do you routinely eat things that are non-food items?
YES
NO
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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)
Other
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7
On a typical day, how many times do you eat fruit?
5 or more
4
3
2
1
None
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8
On a typical day, how many times do you eat vegetables?
5 or more
4
3
2
1
None
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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
Other
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10
What kind of milk do you drink?
Fat-free (skim)
Low-fat (1%)
Reduced fat (2%)
Whole
Not Applicable
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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
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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
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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
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14
On a typical day, how many times do you drink plain water?
4 or more
3
2
1
None
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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
Other
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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
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17
Have you visited a dentist within the past 12 months?
YES
NO
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18
Do you have tooth decay, broken teeth, bleeding gums, missing teeth and/or misplaced teeth that make chewing difficult?
YES
NO
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19
Are you currently pregnant?
YES
NO
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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
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