Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1066A (07/08)

STATE OF WISCONSIN

HEALTHCHECK CHILD'S FOOD RECORD / 1-12 years of age
Completion of this form is voluntary.
NAME - Child TODAY'S DATE

Instructions: Write down everything the child ate or drank in the last 24 hours (meals and snacks). Start with the first morning feeding yesterday to the first morning feeding today. Example: 8:30 AM home sandwich ­ 2 slices whole wheat bread, 2 slices cheddar cheese, and 1 tablespoon butter. 1-cup tomato soup made with 2% milk AMOUNT AND FOOD / BEVERAGE CONSUMED

TIME

PLACE

1. Is this the way this child eats most of the time?

Yes

No

If no, why?

2.

What foods does this child refuse to eat?

3.

How often does this child eat away from home?

1-2 times a week

2-4 times a week

Almost every day

4.

Are mealtimes with this child usually pleasant?

Yes

No

If no, why?

5.

How many times in the last month did the child have problems getting enough food?

Office Use Only

Bread

Vegetables

Fruit

Milk

Meat