Download NEAT-R long assessment - Michigan State University College of

Nutrition Education
Aimed at Toddlers
EHS Toddler Nutrition Questionnaire—Long Action Version
(Intended for use with toddlers 12-36 months)
Child’s Name ______________________________________________
Age ______________ months/years
Sex: M F
Birth date____________
Current weight_______ Percentile _____ Current height_______
Percentile _____
Action message:
Plot the height and weight on the appropriate growth chart.
Determine where the toddler is:
Less than or equal to the 10th percentile = at risk for underweight
Greater than or equal to the 85th through the 95th percentile = at risk for overweight
Greater than or equal to the 95 percentile = overweight
Recent sudden changes or consistently under- or over-weight may be cause for concern.
Refer to a nutritionist and follow-up with the parent regarding the prescribed plan of care.
Is your child on WIC?
Yes No I would like to learn how to enroll
_________
Are you on the FOOD STAMP program?
Yes No I would like to learn how to enroll _________
***************************************************************************************
Current Dietary Intake
1) In a typical day, how many servings does your child eat from each of the following food groups?
Action message: Be sure to specify child-sized servings. Refer to your tool kit for portion sizes. Although
maximum servings are not given, if you feel a child is eating too much of any food, speak to a nutritionist.
Cheese, cottage cheese, yogurt, milk
0
1
2
3
4
5
6+
Action message:
These foods will help your child have healthy bones and teeth. Your child should eat two servings a
day. All children under 2 years of age should be drinking whole milk.
Meat, poultry, fish, eggs; dried beans/peas, tofu
0
1
2
3
4
5
6+
Action message:
These foods will help your child have healthy growth. Your child should eat two servings a day.
Fruits
0
1
2
3
4
5
6+
Action message:
These foods will help your child get the right amount of important vitamins and minerals. Your child
should eat two servings a day.
Vegetables (not potatoes)
0
1
2
3
4
5
6+
Action message:
These foods will help your child get the right amount of important vitamins and minerals. Your child
should eat three servings a day, with at least one being a dark green or deep yellow vegetable.
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1
Bread, grits, cereal, noodles, rice, tortillas, bagels, crackers
0
1
2
3
4
5
6+
Action message:
These foods will help your child grow properly. Your child should eat five to six servings a day of
heart-healthy whole grains, such as whole wheat bread, brown rice, and oatmeal.
2) In a typical WEEK, how often does your child eat from each of the following food groups?
Margarine, butter, lard, oil
1
2
3
4
5
6
7+
Action message:
Eating too much added fats and oils or fatty/oily foods can lead to overweight children, who will have a
greater chance of diabetes or heart disease later in life. Try to limit fried food and use small amounts of
added fats in cooking and on food.
Cakes, cookies, pie, candy, ice cream, donuts
1
2
3
4
5
6
7+
Action message:
Eating too much added sugar, sweets, or sugary foods may lead to overweight and dental cavities. Try to
eat small portions of sweet foods and then eat them less than 3 times a week.
Fast food
1
2
3
4
5
6
7+
Action message:
Fast food often contains a large amount of fat and/or salt. Eating too much of these foods may lead to
overweight children and/or high blood pressure. Try to eat small portions of fast foods and then eat them
less than 3 times a week.
2) Does your child eat any of the following foods? (Circle ALL that apply.)
raw vegetables
hotdogs
chips
popcorn
nuts
marshmallows
hard candy
raisins
seeds
grapes
pretzels
peanut butter on a spoon
Action message: If any of the above foods are circled
These foods can cause small children to choke, because they cannot swallow these types of food as
easily as adults. You should not feed these foods to children under two years old to prevent choking.
3) On a typical day, how many cups (8 oz, sippy cup) of each of the following does your child drink:
Action message:
Too much of any beverage can fill a child’s tummy and they may not have room for their food.
Regular soda-pop, such as Mt. Dew or Pepsi, or Diet soda-pop, such as Diet Coke, or Diet 7-Up ----------------------------------------------------------------------------------------------------- 0
1
2
3
4
more
Action message:
Drinking too much of these types of drinks is not healthy for your child. Both diet and regular soda-pop
may lead to tooth decay. Regular soda may lead to childhood overweight. 100% fruit juice can be a good
alternative to soda, but no more than 1/2 cup or 4 oz of 100% fruit juice per day.
Water, bottled or from the tap, do not include ice ---------------------------- 0
1
2
3
4
more
Action message:
Water should be given to your child throughout the day. You should not add ice to your child’s water
because ice can cause choking.
100% Fruit Juice, such as Libby’s or Juicy Juice ----------------------------- 0
1
2
3
4
more
© Copyright 2007, Michigan State University Board of Trustees, All rights reserved (Horodynski, Stommel, Brophy-Herb, Weatherspoon).
Please continue on the next page
2
Action message:
100% fruit juice is a good alternative to fruit drinks and soda, but don’t give your child a lot of fruit
juice because it has a high sugar content. 1/2 cup or 4 oz of 100% fruit juice a day is about the right
amount.
Other fruit drinks, such as Gatorade, Kool-Aid, ------------------------------ 0
1
2
3
4
more
Hi-C Punch, Lemonade, Iced Tea
Action message:
Drinking too much of these types of drinks may lead to childhood overweight or tooth decay. 100% fruit
juice can be a good alternative to soda, but no more than 1/2 cup or 4 oz of 100% fruit juice per day.
4) How many meals and snacks does your child have in a typical day? _____meals
_____ snacks
Action message:
Emphasize the importance of healthy foods and portion sizes are different for toddlers and adults.
Toddlers’ appetites change from day to day, so tell parents not to force a child to eat if the child is
clearly not hungry.
Because of their small stomachs, toddlers are limited in the amount of food they can eat at any one time.
In a typical day, children should eat about 6 times a day (3 meals, 3 snacks). A healthy snack could be ½
banana or a peach with 1/4 cup of yogurt.
5) Do any of the following interfere with you providing healthy meals and snacks for your child and your
family?
Action message: Sources of Help
a) Cost?
Yes
No
WIC, EFNEP/FNP, Budget assistance,
Nutritionist, Food bank, MSUE
b) Transportation?
(no way to get to store)
Yes
No
Car pool, EHS home visitor
c) Don’t know how to cook?
Yes
No
EFNEP/FNP, MSUE, EHS home visitor,
cookbooks from library
d) Lack of time?
Yes
No
EHS home visitor, MSUE
e) Don’t know what food
to buy?
Yes
No
EFNEP/FNP, Nutritionist, MSUE
f) Don’t know how to feed a toddler? Yes
No
EHS home visitor, MSUE
g) Don’t know how much
to feed a toddler?
No
EHS home visitor, nutritionist, MSU
Yes
h) Other: ____________________________________
Please continue on the next page
Eating/Feeding Behaviors
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3
1) Does your child usually feed himself?
Yes
No
Action message:
As children grow and are able to do more things for themselves, they like to pick up finger foods and try
to use child sized spoons or forks. You can help your child learn to feed him/herself by giving your child
practice in picking up foods and using spoons. Try to be patient as your child learns to eat
independently. It might be a little messy, but practice is how your child learns.
2) Does your child still take a bottle?
Yes
No
Action message:
Children older than 12 months should not be getting anything other than water in a bottle, including
formula or juice. NEVER give a bottle in bed because it may cause them to choke or can promote tooth
decay. Children at this age are developing important muscle skills, including self-feeding. When
children drink from a bottle, they suck instead of sip. They do not have to hold the bottle carefully to
prevent spilling. Drinking from a sippy cup is very similar to drinking from a bottle. Sippy cups are
good for transitioning from a bottle to an adult cup, but should not be used exclusively. Children should
be encouraged to drink from a small glass or cup to develop gross motor skills, both through holding the
cup and drinking from it. Bottles and sippy cups should only be used if child is sitting (as with any
eating or drinking). Sippy cups should generally only contain water. Remind parents that children are
expected to be messy at this age, and the sooner they develop these self-feeding skills, the sooner the
child will be able to drink without making a mess.
3) Do you feel your child is a picky eater?
Yes
No
Action message:
Toddlers are sometimes "picky" eaters. Toddlers may prefer particular food colors, tastes, and textures.
These preferences often fade over time when they are offered new foods, especially if you keep offering
many kinds of foods. It helps if you eat a variety of foods too. Your toddler will be watching to see what
you eat too! Remember that new foods often have to be offered up to 20 times before toddlers accept
them. Try serving new foods along with familiar foods. Your toddler is more likely to try something
new when hungry, and if other family members are eating these foods too. Also, your child’s appetite
will change as they grow and develop. Your toddler may be especially hungry just before and during a
big growth spurt.
4) How would you describe a typical mealtime with your child?
Usually Pleasant
Sometimes Pleasant
Rarely Pleasant
Action message:
If mealtimes feel stressful to you, think about what parts of the meal are most challenging. Knowing
about toddlers' appetites, common mealtime behaviors, and toddlers learning to feed themselves (which
can contribute to messiness) can improve understanding of the overall mealtime experience. Toddlers
also have short attention spans, so remember that toddlers are likely to eat for a short period of time, and
then become interested in something else. When adults and toddlers sit and eat together, toddlers are
more likely to stay at the table and focus on the meal.
5) Does your child sit and eat at a table with the family during most mealtimes?
Yes
No
Action message:
Mealtimes are important times for your family. Mealtimes are also a great time to sit down for a few
minutes with your child. As your child grows up, this time of checking in with your child each day
becomes an important part of knowing how your child is doing, how things are going and so on.
Sometimes, it is tempting for parents to give toddlers something to eat while they are playing or walking
Please continue on the next page
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4
around the house. Eating while moving around and playing can cause toddlers to choke on their foods.
Sitting down at the table is the safest way to eat, and it helps toddlers develop healthy eating habits.
6) How long do mealtimes with your child usually last?
5-10 minutes
11-20 minutes
21-30 minutes
more than 30 minutes
Action message:
Remember that toddlers need time during meals to explore their foods. They like to smell, touch, and
taste food. This is how they learn! Toddlers need time not only to eat, but also to learn to use forks and
spoons, and this takes a lot of practice. Try to avoid battles over food and eating. Toddlers know when
they are hungry and when they are full. If you offer your toddler a variety of foods, he/she will probably
get enough of each kind over the course of a few days. NEVER force a child to eat! Trying to get the
toddler to eat just one more bite will only create a problem.
7) What do you do if your child regularly
won’t eat at your planned meal or
snack-times?
Action message: **If the child is over or underweight, these
actions may not be beneficial. Please follow the directions of a
health care provider in these instances. Also, be sure to give
food before drinks at mealtimes.
a) Make him/her eat?
Yes
No
a) If YES: Children should decide how much they are going to
eat. It is important to NEVER force a child to eat or “clean
his/her plate”.
b) Offer different food?
Yes
No
b) If YES: You don’t help your child by fixing a different meal
or food. If you serve something else, your child will get the
message that you don’t expect him/her to eat it. Make one meal
for everybody with a variety of healthy foods and let your
toddler decide what to eat. If they don’t eat at this meal, they’ll
make up for it at another meal.
c) Offer food later?
Yes
No
c) If YES: Sometimes your child may not be hungry.
Remember to offer healthy meals and snacks at regular times
throughout the day. This will allow your child to become
hungry in between regular feeding times.
d) Offer dessert if he/she will eat?
Yes
No
d) If YES: You should never use food as a reward or
punishment because it could lead to bad food habits. Try to talk
positively to your child instead of giving food as a reward or
punishment.
e) Other: _______________________
e)Action: Help parents understanding typical toddler eating
habits to decrease parents' worrying about their children's food
choices at mealtime and decrease the chance that parents will
force or bribe children to eat.
Allowing your child to choose what and how much he or she eats from what you serve teaches important
skills. When you follow the "parent provides, child decides" approach, children learn to eat as much as
they need. They learn to listen to their own hunger and feelings of fullness. This typically leads to
healthier eating habits.
8) Does your child usually watch TV during mealtimes at home?
Yes
No
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5
9) Does your child usually watch TV during snack times at home?
Yes
No
Action message:
When adults watch TV while they are eating, they tend to lose track of what they are eating. They often
keep eating even when they are full. The same thing can happen with toddlers. If toddlers are watching
TV while they are eating, they don’t learn to pay attention to their own feelings of being full. This can
lead to overeating.
***************************************************************************************
Eating/Feeding Concerns/Problems
1) Does your child have any food allergies?
Yes
No
a) If yes, describe: ___________________________________________________________________
b) How do you know your child has food allergies?
 did you figure it out yourself
 did a doctor tell you?
Action message:
Only 6-8% of children develop true allergies. so it is important to talk to your doctor if you think your
child has a food allergy. If a close family member (parent or sibling) has food allergies it’s a good idea to
wait to introduce foods that are known to cause allergies into your child’s diet until he or she is at least 3
years old. Food that usually cause allergies in children are eggs, milk, peanuts, soy, and wheat. These
are the main foods children may be allergic to. Other foods include tree nuts (walnuts, pecans) fish,
and shellfish.
c) Has a health care provider identified any eating problems your child has (e.g., Failure to Thrive)
Yes
No
Action message:
If YES: determine what the eating problem is. Determine what the health care provider recommended and
the parent’s follow through. Identify if additional assistance is needed. A feeding observation may be
helpful.
For mild malnutrition: parents need to work on ways to increase the toddler’s oral intake, including dietary
supplementation with high-calorie foods and food additives, such as sour cream, butter and cheese, an also
the use of a multivitamin. Provide parents with assistance on feeding techniques such as decreasing
excessive juice intake (if more than 4-6 oz a day), reducing between meal grazing, and ensuring that there
is adequate food in the home.
For moderate to severe malnutrition: refer, then help parents adhere to the prescribed medical and dietary
regime.
For overeating: Parents need to encourage moderation in dietary portions and feeding rather than overconsumption. Parents also need to emphasize healthful choices rather than restricted eating patterns.
Remind parents to avoid (DO NOT BUY) calorie dense foods and substitute fruit and vegetable snacks
and water for sugared sodas, juices, and cookies. If possible, the obese child and the entire family should
adhere to a similar diet plan. Some good tips include:




Decrease fast food and eating out.
Do not eat in front of the television.
Do not use food as Please
a reward. continue
Encourage the family to eat meals together.
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6




Serve right sized portions.
Schedule toddler’s meals and snacks at regular times.
Limit snacks to 3 a day: mid-morning, mid-afternoon, bedtime.
Teach child to eat slowly.
d) Have you noticed any other eating problems that your health care provider has not identified?
Yes
No
Probes you can use:
 refusing bottle/food
 gagging on textured food
 not progressing with age-appropriate diet
 behind in age-appropriate feeding skills
 prolonged time to complete a meal
 Other: ________________________________________________________
Action message:
If YES: Determine if a referral to a health care provider and/or nutritionist is needed. Gagging and
choking are realistic concerns for toddlers. Toddlers should only be given foods that gradually build selffeeding skills, starting with ground, mashed, or soft (baby food consistency) foods and building to
prepared table foods by 15 to 18 months.
Foods that may be hard to control in the mouth and may be easily lodged in the esophagus should be
avoided, such as nuts, raw carrots, popcorn, and round candy. Other potentially problematic foods like hot
dogs, grapes, and string cheese may be modified by cutting them into small pieces.
The parent should always be present during feeding and children should be seated in a high chair or other
chair during mealtimes. Eating in the car should be discouraged. Also try determine if the eating problem
is related to the parental situation (depression, familial stress, mealtime interaction, force-feeding).
‘Dawdling’ or playing with foods is a part of normal behavior for a child. After a reasonable amount of
time (10-15 minutes), remove the uneaten food without a fuss.
e) Has there been a change in your child’s appetite in the last month?
Yes
No
i) Describe: _____________________________________________________________________
Action message:
If YES: Determine what may be the cause. Toddlers tend to go on food “jags” where certain foods are
preferentially consumed. Toddlers have small and fluctuating appetites. They do best when fed 3 meals
and up to 3 snacks a day.
Give your child a variety of healthy foods, combining favorite foods with new foods. If your toddler does
not like green beans the first time, keep trying, up to 20 more times. Keep reintroducing the new food
without nagging or forcing your child to eat. Just make small portions available. It sometimes takes
repeated opportunities for the toddler to try a new food, even up to 20 times, before they decide to eat it.
So, keep trying but don’t make your toddler eat the food. Putting it on the plate keeps eating it an option;
one time your child may decide to try it.
It is surprising how little food a toddler really needs to eat. From 18 months until 3 years of age, a
toddler’s rapid growth slows down. Toddlers are less hungry so food intake decreases. It is common for
toddlers eat a lot of one thing for a while and then refuse it.
2) Does your child drink fluoridated water?
Yes
a) If no, does your child take Topical Fluoride Applications or Fluoride Supplement? Yes
Action message:
Please continue on the next page
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No
No
7
If the fluoride content of the water source is unknown, it is important to have the water tested before
prescribing a fluoride supplement. If the child is taking a supplement, review directions with parents, such
as taking on an empty stomach, or with milk
3) Is your child on a special diet for medical reasons?
Yes
No
a) If yes, what type? ___________________________________________________________________
Action message:
If YES: describe what the diet is. Determine the parent’s adherence. Identify if referral or assistance is
needed.
4) Has your child been tested for lead poisoning?
Don’t Know Yes
No
a) If yes, what were the results:
positive
negative
b) If positive, were any actions taken? ___________________________________________________
Action message:
Screening for lead toxicity and anemia should be considered because 50% of children with growth failure
have iron deficiency and lead intoxication. Children should be tested at 12 months, and again at 24
months. Lead poisoning may be hard to detect at first until levels build up. Signs and symptoms include:
irritability, loss of appetite, weight loss, sluggishness, abdominal pain, vomiting, constipation, and
pallor.
If YES and/or POSITIVE: Children can get lead poisoning by chewing on a lead painted windowsill,
eating lead paint chips, or from getting lead dust into their mouths. Some ways to prevent lead poisoning
are:
 Keep children away from peeling or chipping paint, especially windows.
 Wet mop and wipe dry hard surfaces with automatic dishwasher soap and water.
 Wash children’s hands and faces before they eat.
 Wash toys and pacifiers frequently.
 Make sure children eat regular nutritious meals and that the diet contains plenty of iron. Examples of
foods high in iron are: fortified cereal, cooked beans, spinach, liver, and dried fruits.
 Do not store foods in open cans.
 Do not serve food in pottery that is decorative.
 Do not store foods or beverages in lead crystal or china.
 Run cold water for at least a minute before drinking, especially if you have older plumbing.
5) Are dental issues a concern?
Yes
No
a) If yes, describe: __________________________________________________________________
Action message:
You can clean your toddler’s teeth with a clean washcloth until his or her back molars come in, usually
around 18 months. After 18 months, you can use plain water and a soft child’s toothbrush. Dentists
recommend waiting until children are at least 2 years of age to use fluoridated toothpaste and then only a
pea size drop each time. Make sure you rinse your child’s mouth thoroughly when you use fluoridated
toothpaste.
Is there anything else you would like us to know about your child’s eating habits? ______________________
________________________________________________________________________________________
________________________________________________________________________________________
Food Safety
1) Does your child wash
his/her hands
with soap and
andpage
after eating?
Please
continue
onwater
thebefore
next
With assistance
Without assistance
Not at all
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8
Action message:
Teaching your children how to wash their hands properly is a big part of keeping them safe from disease.
A study by the FDA found that children who washed their hands 4 times a day had 24% fewer sick days
due to respiratory illness and 51% fewer days due to upset stomach.
2) What best describes how often you wash your hands with soap and water before preparing food for your
child?
Usually
Sometimes
Rarely
Action message:
You should wash your hands for 20 seconds (long enough to sing your ABC’s or the National Anthem)
with hot soapy water before serving or eating foods to remove disease carrying bacteria and viruses. This
is especially important when handling meat or eggs, since these bacteria can be fatal to young children.
3) Do you wash your raw fruits and vegetables before eating them?
Usually
Sometimes
Rarely
Action message:
You should wash your hands with warm soapy water before preparing raw fruits and vegetables. Rinsing
fruits and vegetables under warm running water that is safe enough to drink is considered the best way to
remove dirt and residue, however fruits and vegetables that have firm surfaces, such as melons, potatoes
and carrots can also be scrubbed.
**************************************************************************************
Physical Activity
1) How much time out of an average day does your toddler spend actively playing, such as walking, toddling,
running, pushing toys, rolling around on the floor, throwing a ball, rolling objects on the floor, climbing,
jumping, twirling, dancing, moving around?
Wake-up Time until Noon
_____ 0 minutes
_____ 1-15 minutes
_____ 16-30 minutes
_____ 31-60 minutes
_____ Over 60 minutes
Noon until 6 p.m.
_____ 0 minutes
_____ 1-15 minutes
_____ 16-30 minutes
_____ 31-60 minutes
_____ Over 60 minutes
6 p.m. until bedtime
_____ 0 minutes
_____ 1-15 minutes
_____ 16-30 minutes
_____ 31-60 minutes
_____ Over 60 minutes
Action message:
Most toddlers enjoy basic movement skills such as running, jumping, throwing, and kicking. Try to offer
toys that encourage your toddler to use muscles. Building with blocks made of paper milk cartons, using
ride on toys, playing with balls and beanbags, and climbing are all great activities to help your toddler be
active and grow. Toddlers need more than 60 minutes of unstructured physical play in a safe place every
day. Parents should be engaging in 30 minutes of activity a day themselves, and your being active is an
important model for your toddler. Healthy habits start early. Children who are active early on tend to
continue to be healthy and active later on in life.
Are there any concerns you would like more information about?
Yes
No
If yes, list_____________________________________________________________________________
Please continue on the next page
_____________________________________________________________________________________
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9
What method do you prefer to receive nutrition education (please circle)
Handouts
Speakers at parent meetings
Individual counseling
Other: ______________________________________________________________
Have you used nutritional materials provided by Early Head Start?
Yes
No
If yes, which ones would you recommend for new EHS parents or a friend? _____________________
__________________________________________________________________________________
__________________________________________________________________________________
***************************************************************************************
Your child’s Pediatric/Family Physician is: __________________________________________________
Physician’s Phone Number: ______________________________________________________________
In giving this information, I give permission for the Registered Dietitian to contact me and/or my child’s
physician.
Yes
No
Parent’s Signature: _____________________________________________________________________
***************************************************************************************
Referral Made:
Yes
No
Date referred to R.D. _________________________________
Comments:
Staff Signature: __________________________________________
Date: ________________
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10
***************************************************************************************
Do you or the parent feel the family requires more education in any of the following? Please check.
_____ How to help an over/under weight child
_____ Nutritious snacks
_____ How to help a picky eater
_____ Nutritious low cost meals
_____ Appropriate beverage intake (juice, pop)
_____ Supplementing child’s diet
_____ Food groups
_____ Nutritional needs of toddlers
_____ Lowering fat and/or sugar in diet
_____ Healthy recipes
_____ Kitchen safety and sanitation
_____ Ideas for increasing movement
_____ Mealtime Behaviors (TV, sitting)
_____ Other, specify
***************************************************************************************
Action Taken:
Staff Signature: __________________________________________
Date: ________________
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11
Risk Score
Section 1: Is the child within a normal height and weight percentile range? Please refer to CDC growth
charts:
5 points
3 points
0 points
3 points
5 points
1. Height (Length) percentile?
___ <5%
___ 5-10
___ 10-90
___ 90-95
___ >95
2. Weight percentile?
___ <5%
___ 5-10
___ 10-90
___ 90-95
___ >95
(Score of 3 requires referral to RD) Section 1 Total score: _______________
Section 2: Does the child eat appropriate servings of each of the following food groups? Score one point for
each NO.
Yes
No
1. Appropriate servings of Cheese, yogurt, milk? (at least 2 servings)
___
___
2. Appropriate servings of Meat, eggs, dried beans/peas, etc? (at least 2)
___
___
3. Appropriate servings of Fruits? (at least 2)
___
___
4. Appropriate servings of Vegetables (not potatoes)? (at least 3)
___
___
5. Appropriate servings of Bread, cereal, noodles, rice, etc.? (at least 5)
___
___
6. Appropriate servings of Margarine, butter, lard, oil? (no more than 2)
___
___
7. Appropriate servings of Cakes, cookies, pie, etc.? (no more than 2)
___
___
8. Appropriate servings of Fast food? (no more than 2)
___
___
(If parent scores any points, provide additional education)
Section 2 Total score: _______________
Section 3: Does the child eat any of these foods? Score one-point for each YES.
Yes
1. chips
___
2. popcorn
___
3. nuts
___
4. marshmallows
___
5. hard candy
___
6. raisins
___
7. seeds
___
8. pretzels
___
(If parent scores any points, provide additional education)
Section 3 Total score: _______________
Section 4: Does the child drink appropriate servings of the following beverages?
Score one point for each NO
Yes
1. Regular or Diet soda-pop (no more than 2 servings)
___
2. Water (at least 3)
___
3. 100% Fruit Juice (between 1 and 2)
___
4. Other fruit drinks (no more than 2)
___
(If parent scores any points, provide additional education)
No
___
___
___
___
___
___
___
___
No
___
___
___
___
Section 4 Total score: _______________
Add scores together (Section 1 + Section 2 + Section 3 + Section 4) Total Score: _________
A score of 10 or greater should be referred to an RD for additional assessment
© Copyright 2007, Michigan State University Board of Trustees, All rights reserved (Horodynski, Stommel, Brophy-Herb, Weatherspoon).
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