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Nutrition Assessment-12 months to Preschool
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* Indicates required question
Child's Name (Last, First)
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Your answer
Child's Date of Birth
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MM
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DD
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YYYY
Child's Gender
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Female
Male
NUTRITIONAL INFORMATION
MyPlate is a tool that can help families implement healthier eating habits. Below are MyPlate questions.
MyPlate encourages half of the plate at meals to be from fruits and vegetables . Do fruits and veggies make up half of your child’s plate at meals?
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Yes
No
Sometimes
MyPlate encourages half of the grains you eat to be whole grains. Are half of the grains your child eats from whole grains?
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Yes
No
Sometimes
MyPlate encourages eating from a variety of protein sources daily. Does your child eat from a variety of protein sources daily (seafood, eggs, lean meats, beans, nuts, etc.)
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Yes
No
Sometimes
MyPlate encourages dairy at each meal. Does your child consume 1 serving of dairy at meals?
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Yes
No
Sometimes
MyPlate encourages limiting added sugars in daily intakes . Does your child have 2 or fewer servings daily of sugary items (soda, sweets, fruit drinks like Capri Sun, candy, or dessert)?
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Yes
No
Sometimes
Is water your child’s main beverage of choice?
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Yes
No
Sometimes
HEALTH HISTORY
Does your child take any medications, vitamins or supplements?
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Yes
No
If your child takes any medications, vitamins or supplements please list:
Your answer
Does your child have health needs that require a specialized diet (food allergies, gluten intolerance, etc.)?
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Yes
No
If your child has health needs that require a specialized diet (food allergies, gluten intolerance, etc.) please describe:
Your answer
Are there foods your child shouldn’t eat for religious or personal reasons?
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Yes
No
If there are foods your child shouldn’t eat for religious or personal reasons please describe:
Your answer
In giving this information, I give permission for the Nutrition Coordinator to review this information and to contact the child’s parent/guardian and/or physician, if needed.
By choosing Yes to this question you agree that the above information provided is correct. Also that by choosing yes this is the equivalent of a signature.
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Yes
Date Form Completed
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MM
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DD
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YYYY
Parent/Guardian Completing This Form
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Your answer
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