THIRD-YEAR QUESTIONNAIRE

Section G:

UPDATE ON YOUR CHILD’S DIET

See TYQ033103_part1.pdf for the first part of the

Third Year Questionnaire

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SECTION G: UPDATE ON YOUR CHILD’S DIET

A reminder when we mention your child, we mean the 3 year-old child named on the cover page.

G1. In the past month, has your child taken any of the following vitamins or supplements?

Yes No a) Chewable multi-vitamin (for example Flintstones, Sesame

Street, Centrum)

1 2

b) Multi-vitamin drops such as Tri-Vit (Tri-Vi-Sol) or Poly-Vi-Sol 1 2

c) Fluoride drops, for example, Tri-Vi-Flor or Poly-Vi-Flor 1 2

d) Iron drops 1 2

e) Other vitamins or supplements: Specify________________ 1 2

Please indicate how much you agree or disagree with each of the following statements.

Strongly agree Agree Disagree Strongly

Disagree

G2. I often have to encourage my child to eat more 1 2 3 4

G3. I have to be sure that my child finishes everything in the cup 1 2 3 4

G4. I have to be sure that my child finishes all the food on the plate 1 2 3 4

G5. If my child refuses to eat a new food, I continue to offer it to him/her at other times

1 2 3 4

G6. My child likes vegetables 1 2 3 4

G7. My child likes fruits 1 2 3 4

G8. My child usually likes new foods 1 2 3 4

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G9. I have to be careful not to feed my child too much 1 2 3 4

G10. I often prepare something else if my child doesn’t eat what I first offer 1 2 3 4

Please indicate how much you agree or disagree with each of the following statements.

Strongly agree Agree Disagree Strongly

disagree

G11. I have to be sure that my child does not eat too many sweets (candy, ice cream, cake). 1 2 3 4

G12. I have to be sure that my child does not eat too much of his/her favorite foods. 1 2 3 4

G13. I have to be sure that my child does not eat too many junk foods. 1 2 3 4

G14. The questions on these last few pages are about your child’s diet over the past month. Please check the box that best represents how often your child eats each of the foods listed, on average, in the past month.

A. Fruits Never

Less than once per

week

Once per

week

2 – 4 times

per week

Nearly daily

or daily

2 or more times

per day

1. Orange or grapefruit 1 2 3 4 5 6

2. Banana 1 2 3 4 5 6

3. Apple or apple sauce 1 2 3 4 5 6

4. Grapes 1 2 3 4 5 6

5. Peach or plum 1 2 3 4 5 6

6. Strawberries or other berries 1 2 3 4 5 6

7. Cantaloupe 1 2 3 4 5 6

8. Watermelon 1 2 3 4 5 6

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9. Pear 1 2 3 4 5 6

10. Raisins or prunes 1 2 3 4 5 6

Please check the box that best represents how often your child eats each of the foods listed, on average, in the past month.

B. Vegetables Never

Less than once per

week

Once per

week

2 – 4 times

per week

Nearly daily

or daily

2 or more times per day

1. Corn 1 2 3 4 5 6

2. Peas (canned, frozen or fresh) 1 2 3 4 5 6

3. Tomatoes 1 2 3 4 5 6

4. Peppers (green, red, or hot) 1 2 3 4 5 6

5. Carrots 1 2 3 4 5 6

6. Broccoli 1 2 3 4 5 6

7. Green beans 1 2 3 4 5 6

8. Spinach 1 2 3 4 5 6

9. Squash (orange or winter) 1 2 3 4 5 6

10. French fries, fried potatoes 1 2 3 4 5 6

11. Potatoes (baked, boiled or mashed) 1 2 3 4 5 6

12. Sweet potatoes or yams 1 2 3 4 5 6

13. Cabbage, coleslaw, or cauliflower 1 2 3 4 5 6

14. Lettuce salad 1 2 3 4 5 6

15. Mixed vegetables 1 2 3 4 5 6

16. Baked beans or chili beans 1 2 3 4 5 6

17. Other dried beans, dried peas or lima beans 1 2 3 4 5 6

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Please check the box that best represents how often your child eats each of the foods listed, on average, in the past month.

C. Meat, fish and other main dishes

Never

Less than once per

week

Once per

week

2 – 4 times

per week

Nearly daily

or daily

2 or more times

per day

1. Pizza 1 2 3 4 5 6

2. Macaroni and Cheese 1 2 3 4 5 6

3. Peanut Butter 1 2 3 4 5 6

4. Hamburger, meatballs, or meatloaf 1 2 3 4 5 6

5. Beef – steak or roast 1 2 3 4 5 6

6. Pork - chops, roast, or ribs 1 2 3 4 5 6

7. Ham - baked or steak 1 2 3 4 5 6

8. Cold cuts (baloney, salami, ham) 1 2 3 4 5 6

9. Sausage 1 2 3 4 5 6

10. Bacon 1 2 3 4 5 6

11. Hot dogs 1 2 3 4 5 6

12. Fried chicken, chicken nuggets 1 2 3 4 5 6

13. Other chicken or turkey 1 2 3 4 5 6

14. Canned tuna 1 2 3 4 5 6

15. Fried fish, fish sticks 1 2 3 4 5 6

16. Other fish 1 2 3 4 5 6

17. Tofu or soy beans 1 2 3 4 5 6

18. Vegetable soup 1 2 3 4 5 6

19. Other soup 1 2 3 4 5 6

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Please check the box that best represents how often your child eats each of the foods listed, on average, in the past month.

D. Starches and grains Never

Less than once per

week

Once per

week

2 – 4 times

per week

Nearly daily

or daily

2 –4 times

per day

5 or more times per day

1. Pasta 1 2 3 4 5 6 7

2. White Rice 1 2 3 4 5 6 7

3. Brown Rice 1 2 3 4 5 6 7

4. White Bread (slice, rolls or pita) 1 2 3 4 5 6 7

5. Dark bread (slice, rolls or pita) 1 2 3 4 5 6 7

6. Cornbread or tortilla 1 2 3 4 5 6 7

7. Cereal (hot) 1 2 3 4 5 6 7

8. Cereal (cold) 1 2 3 4 5 6 7

9. Donut, fried dough 1 2 3 4 5 6 7

10. Sweet roll or muffin 1 2 3 4 5 6 7

11. Pancake, waffle, or French toast 1 2 3 4 5 6 7

12. English muffin or bagel 1 2 3 4 5 6 7

13. Biscuit 1 2 3 4 5 6 7

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Please check the box that best represents how often your child eats each of the foods listed, on average, in the past month.

E. Drinks Never

Less than once per

week

Once per

week

2 – 4 times

per week

Nearly daily

or daily

2 –4 times

per day

5 or more times

per day

1. Milk, including chocolate milk 1 2 3 4 5 6 7

2. Hot Chocolate 1 2 3 4 5 6 7

3. Orange Juice 1 2 3 4 5 6 7

4. Other 100% juice 1 2 3 4 5 6 7

5. Fruit drinks (Hi-C, Kool-Aid, lemonade) 1 2 3 4 5 6 7

6. Soda (not sugar-free) 1 2 3 4 5 6 7

7. Sugar-free soda 1 2 3 4 5 6 7

8. What kind of milk does your

child usually drink?

3 Whole milk

4 2 % milk

5 1% milk

6 Skim milk

7 Soy milk

8 Other (Please specify:____________________________)

9 My child does not drink milk

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Please check the box that best represents how often your child eats each of the foods listed, on average, in the past month.

F. Other Dairy Never

Less than once per

week

Once per

week

2 – 4 times

per week

Nearly daily

or daily

2 or more times

per day

1. Cheese, plain or in sandwiches 1 2 3 4 5 6

2. Cream cheese 1 2 3 4 5 6

3. Cottage cheese 1 2 3 4 5 6

4. Yogurt 1 2 3 4 5 6

5. Ice cream 1 2 3 4 5 6

6. Pudding 1 2 3 4 5 6

7. Whole eggs 1 2 3 4 5 6

G. Oils and spreads Never

Less than once per

week

Once per

week

2 – 4 times

per week

Nearly daily

or daily

2 –4 times

per day

5 or more times

per day

1. Butter (not margarine) 1 2 3 4 5 6 7

2. Margarine (tub) 1 2 3 4 5 6 7

3. Margarine (stick) 1 2 3 4 5 6 7

4. Mayonnaise 1 2 3 4 5 6 7

5. Salad dressing 1 2 3 4 5 6 7

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Please check the box that best represents how often your child eats each of the foods listed, on average, in the past month.

H. Snacks and sweets Never

Less than

once per week

Once per

week

2 – 4 times

per week

Nearly daily

or daily

2 –4 times

per day

5 or more times

per day

1. Chips (potato, corn or others) 1 2 3 4 5 6 7

2. Nuts 1 2 3 4 5 6 7

3. Crackers 1 2 3 4 5 6 7

4. Jello 1 2 3 4 5 6 7

5. Cookies or brownies 1 2 3 4 5 6 7

6. Cake or cupcake 1 2 3 4 5 6 7

7. Pie 1 2 3 4 5 6 7

8. Chocolate candy 1 2 3 4 5 6 7

9. Other candy 1 2 3 4 5 6 7

Are there any other foods not mentioned above that your child eats at least once per week? Please write in the name of the food and check the box that best represents how often your child eats each food, on average, in the past month.

I.

Other foods your child eats at least once per week

Once per

week

2 – 4 times per

week

Nearly daily

or daily

2 –4 times

per day

5 or more times per day

For Study Staff

Only

1. 3 4 5 6 7 ___ ___ ___

2. 3 4 5 6 7 ___ ___ ___

3. 3 4 5 6 7 ___ ___ ___

4. 3 4 5 6 7 ___ ___ ___

5. 3 4 5 6 7 ___ ___ ___

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G15. In the past month, has your child followed a special diet prescribed by a health care professional?

1 Yes (Please specify: __________________________________)

2 No

G16. In the past month, has your child avoided any foods because of a food allergy, intolerance, or sensitivity?

Yes, (Please specify: ______________________________________)

2 No

G17. In the past month, on average, how often did your child eat something from a fast food restaurant (McDonald’s, Burger King, Taco Bell, etc.)?

1 Never/less than once per month

2 1 – 3 times per month

3 Once per week

4 2 – 4 times per week

5 5 – 6 times per week

6 Once per day or more

Please fill in today’s date:

__ __ / __ __ / __ __ __ __ MONTH / DAY / YEAR

THANK YOU!

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