Kindergarten Health History Template - Multicare Associates Page 4
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438. Do you anticipate any problems in school?
YES
NO
SOMETIMES
39. Are there any problems at home or in the neighborhood that
might trouble him or have effect on his emotions or behavior?
YES
NO
SOMETIMES
40. Are there any problems or characteristics of behavior, emotions, or
development that you have wanted to talk over with a doctor?
YES
NO
SOMETIMES
Are there any of these that are troubling you now?
YES
NO
___________________________________________________________________________________________
___________________________________________________________________________________________
E. FOOD INTAKE RECORD
1.
1. Does your child eat one or more of the following foods every day?
Oranges, Orange Juice, Grapefruit Juice, Cantaloupe, Fresh Strawberries,
Broccoli, Brussel Sprouts? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
2. Does your child eat one or more of these following foods three times a week or more?
Carrots, Pumpkin, Sweet Potatoes, Spinach,Winter Squash,Apricots,
Cantaloupe, Tomatoes or Tomato Juice? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
3. Does your child eat two or more servings of any combination of the
following foods every day?
Potatoes, Cabbage, Cauliflower,Watermelon, Lettuce, Plums, Peaches,
Grapes, Bananas,Apples, Green or Wax Beans, Corn, Peas,Asparagus,
or additional servings of the fruits and vegetables listed in questions 1 & 2 above? . . . .
YES
NO
11. 1. Does your child drink milk fortified with Vitamins A & B? . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
2. How much milk does your child drink in a 24 hour period?
a. Less than 2 cups (16 ounces) each day? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
b. 2-4 cups (16-32 ounces) each day? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
c. More than 4 cups each day? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
3. Does your child eat other foods made with milk every day?
Cheese, pudding, yogurt, cream soups, ice cream . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
111. 1. Does your child eat one or more servings of the following foods every day?
a. meat, fish poultry? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
b. Lunch meat, hot dogs, baked beans, split peas? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
c. Peanut butter (2 tablespoons) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
d. Liver or liver sausage (Braunschweiger) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
e. Eggs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
I V. 1. Does your child eat 4 or more servings every day from the following foods?
Whole grain or enriched bread, rolls, crackers, cereal (cooked or
ready to eat), waffles, pancakes, macaroni, noodles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
2. What brand of cereal does your child generally eat?_______________________________
V.
1. Does your child eat three or more servings of the following foods every day?
Pre-sweetened cereals, candy, cake, doughnuts, pie, cookies,
pop, Kool-Aid, fruit drinks (Tang, Hawaiian Punch, Hi-C,
etc.), jelly, honey, potato chips, popcorn, corn chips . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
2. Does your child take vitamins regularly? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If yes, do they contain iron? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
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