Nutrition Assessment

Assessment Form

Child’s Name:_______________________ Date of Birth:__________________

Birth:_______________________ 
_____ 
Date:______________________________ Center:____________________________ 

1. What types
types of
of fluids
fluids does your
your child
child usual
usually
ly drink
drink

Whole milk  !" #ilk  1" #ilk  $uice

Water %ool&Aid 'ther:_____________________ 

!. Does your child take (itamins )es No

*. Does your
your child
child ha(e any kno+n
kno+n food aller,ies
aller,ies or is
is he-she on a special
special diet
diet
f )es/ 0leas eplain:_____________________________________________ 
No

2. Are you concerned a3out your child’s +ei,ht

f )es/ please eplain:____________________
eplain:____________________________________________ 
________________________ 
No

4. Do you ha(e any

any concerns
concerns a3out
a3out your
your child’s
child’s eatin, ha3its
f )es/ please eplain:____________________________________________ 

No

5. s your child participatin, in WC )es No

6. Does your child still drink from a 3ottle )es No

7. #eal
#eal time
time ha3its:
ha3its: 0lease
0lease che
check
ck the follo+in
follo+in,:
,:

Al+ays 8sually 9ometimes Ne(er

 epect my child to clean their plate.
#ealtime is a pleasant family time.
 limit the amount  let my child eat.
We sit to,ether durin, mealtimes.
o+ often is the ;< on durin,
mealtime
#y child ser(es him-herself durin,
meals.
 =. o+ many times a day does your child usually eat/ includin, snacks_______ 
What types of snacks does he-she eat most often________________________ 

1>. What are your child’s fa(orite foods__________________________________ 

11. What are your child’s least fa(orite foods_____________________________ 

1!. 0lease estimate ho+ often your child eats the follo+in, foods:

Ne(er 'nce 9e(eral 'nce ;+o or

'r A ;imes A #ore ;imes
?arely Week  A +eek  Day A Day
Dairy 0roducts
 @cheese/ yo,urt/ milk
#eat 0roducts
@3eef/ chicken/ e,,s
'ther 0rotein
 @dried 3eans/ e,,s/ peanut 3utter
Bread 0roducts
 @3read/ rice/ pasta/ cereal/ tortillas
Fruit 0roducts
 @3ananas/ oran,es/ apples/ uice
<e,eta3le 0roducts
@corn/ ,reen 3eans/ carrots
9+eets
@cakes/ cookies/ candy/ chips/ soda
Fats
 @3utter/ oil/ mar,arine/ mayo

1*. Do you ha(e any other concerns a3out your child’s ,ro+th or diet
f )es/ please
eplain:_____________________________________________ 
No

0arent 9i,nature:____________________________ Date:____________________ 

?e(ie+ed !>1!