Child Eating Behavior Questionnaire Form
Please complete this questionnaire to help us understand your child's typical eating habits and mealtime behaviors. All questions are about everyday experiences and are not intended for medical use.
What is your relationship to the child?
*
Please Select
Parent
Grandparent
Guardian
Other Relative
Other
What is the child's age range?
*
Please Select
1–2 years
3–4 years
5–7 years
8–10 years
11–13 years
How would you describe the child's typical appetite?
*
Very small
Small
Average
Large
Very large
How responsive is the child to food cues (e.g., asking for food when seeing or smelling it)?
*
Not at all responsive
1
2
3
4
Very responsive
5
1 is Not at all responsive, 5 is Very responsive
How easily does the child feel full during meals (satiety responsiveness)?
*
Rarely feels full
1
2
3
4
Very easily feels full
5
1 is Rarely feels full, 5 is Very easily feels full
How often does the child eat in response to emotions (emotional eating)?
*
Never
1
2
3
4
Very often
5
1 is Never, 5 is Very often
How fussy or selective is the child about foods (food fussiness)?
*
Not fussy at all
1
2
3
4
Very fussy
5
1 is Not fussy at all, 5 is Very fussy
How much does the child desire to drink (e.g., asks for drinks during or between meals)?
*
Not at all
1
2
3
4
Very much
5
1 is Not at all, 5 is Very much
Are there any concerns about the child's mealtime behaviors?
*
No concerns
Occasional concerns
Frequent concerns
Other
Please provide any additional notes or context about the child's eating habits or mealtime behaviors.
Submit
Should be Empty: