Kids Healthy Eating Questionnaire
Help us understand your child's eating habits to promote healthier choices.
Child's Full Name
*
First Name
Last Name
Child's Age
*
Parent or Guardian's Name
*
First Name
Last Name
How many meals does your child usually eat per day?
*
1 meal
2 meals
3 meals
More than 3 meals
How often does your child eat fruits and vegetables?
*
At every meal
Once a day
A few times a week
Rarely
Please rate your child's preference for the following foods:
*
Rows
Dislikes
Neutral
Likes
Vegetables
1
2
3
Fruits
4
5
6
Whole grains
7
8
9
Dairy products
10
11
12
Lean meats or plant proteins
13
14
15
How often does your child drink sugary beverages (e.g., soda, juice drinks)?
*
Never
Once a week or less
A few times a week
Daily
On a typical day, how many servings of vegetables does your child eat?
*
Please Select
None
1 serving
2 servings
3 servings
4 or more servings
How often does your child eat breakfast?
*
Every day
Most days
Sometimes
Rarely/Never
How often does your child snack between meals?
*
Never
Once a day
A few times a day
Please rate your child's overall interest in trying new foods.
*
1
2
3
4
5
Please share any additional comments or concerns about your child's eating habits.
Submit Questionnaire
Should be Empty: