Child Nutrition Assessment

Child’s Name: Date of birth:

Name of person completing form: Relationship to child:

Head Start Center:

What foods does your child especially like?

What foods does your child dislike?

How would you describe your child’s eating? ☐ Good ☐ Picky ☐ Too much ☐ Too little

Does your child eat other things than food? ☐ Yes ☐ No Explain:

Does your child take vitamin/mineral supplements? ☐ Yes ☐ No If yes, what kind?:
If yes, do they contain: ☐ Iron ☐ Flouride

Does your child have trouble chewing or swallowing? ☐ Yes ☐ No Explain:

Do you consider your family’s nutrition habits to be healthy? ☐ Yes ☐ No Explain:

What does your child eat on most days? (check all that apply): ☐ Grains ☐ Vegetables ☐ Fruit
☐ Meat/beans ☐ Milk or milk products ☐ Sweets ☐ Fats (oil, butter)

What does your child drink on most days? (check all that apply): ☐ Juice ☐ Soda ☐ Kool-aid
☐ Whole milk ☐Low fat milk ☐ Sports drink ☐ Water ☐ Other

Do you consider your child to be physically active? ☐ Yes ☐ No Explain:

Have you or your doctor ever had concerns about your child’s weight? ☐ Yes ☐ No

If you answer Yes to the following questions, additional paperwork must be completed

Are there any foods your child does not eat due to religious, cultural, or medical reasons?
☐ Yes ☐ No Explain:

Does your child have food allergies or a special diet prescribed by a Health Care Provider?
☐ Yes ☐ No Explain:

Head Start Personnel: Date:

2019-2020