Robert Kushner

“Pediatric Dietary and Physical Activity Questionnaire Please complete this from as accurately as possible. There are no right or wrong answers. This information will help us get a better picture of your child’s current daily patterns. Dietary Patterns: How many meals does your child eat on a typical day? _______ per day Does your child regularly eat: Breakfast Lunch Dinner Yes _____ No _____ Yes _____ No _____ Yes _____ No _____ How many snacks does your child eat on a typical day? _______ per day What types of snacks does your child typically eat? ___________________ How many servings of fruits does your child eat on a typical day? (circle one) None 1 2 3 4 5 or more How many servings of vegetables does your child eat on a typical day? (circle one) None 1 2 3 4 5 or more Select the types of drinks your child normally consumes: ■ Juice ■ Lemonade ■ Sports Drinks ■ Sweetened Coffee ■ Regular Soda ■ Sweetened Tea ■ Energy Drinks On a typical day, how many of these types of drinks does your child consume (count them all together & enter the total here)? ____________ Who normally prepares the food in the house? ■ Mom ■ Dad ■ Grandparent ■ This Child ■ Sibling ■ Other: ____________ Who normally does the grocery shopping in the house? ■ Mom ■ Dad ■ Grandparent ■ This Child ■ Sibling ■ Other: ____________ How many times per week do you eat together as a family? (circle one) Never 1 2 3 4 5 or more How many times per week does your child eat fast food? (circle one) Never 1 2 3 4 5 or more Concerns about your child’s eating habits: Are you satisfied with your child’s eating habits? Do you have concerns about your child’s portion sizes? Does your child ever eat in secret or sneak food? Does your child ever eat to make himself/ herself happy, or to feel better? Does your child’s weight affect how he/ she feels about himself/ herself? Yes _____ No _____ Yes _____ No _____ Yes_____ No _____ Yes _____ No _____ Yes_____ No _____ Physical Activity and Screen Time: How many times per week is your child physically active (i.e., His or her breathing gets faster)? (Circle one that best describes a typical week) Never 1-2 days/ week 3-4 days/ week 5-6 days/ week Daily What types of physical activities does your child like to participate in? _________________________ How many hours does your child watch TV/ movies, sit at the computer, play video games, or spend time on a phone or tablet on a typical weekday ? ___________ hours/ day How many hours does your child watch TV/ movies, sit at the computer, play video games, or spend time on a phone or tablet on a typical weekend day ? ___________ hours/ day Sleep Behaviors: Does your child have a TV or other screen device (e.g., smart phone) in the room where they sleep? Yes _____ No _____ What time does your child typically go to bed during the week ? _____________ What time does your child typically fall asleep after going to bed during the week ? _____________ What time does your child typically wake up during the week ? _____________ What time does your child typically go to bed during the weekend ? _____________ What time does your child typically fall asleep after going to bed during the weekend ? _____________ What time does your child typically wake up during the weekend ? _____________ Which of the following habits (if any) do you feel ready to help your child and family to change? Check all that apply: ■ Drink less soda or juice ■ Choosing healthy snacks ■ Eating more fruits & vegetables ■ Eat less fast food ■ Eat more meals as a family ■ Plan out meals ■ Play outside/ be more active more often ■ Spend less time watching TV & playing video games or on the computer ■ Take the TV/ Computer out of the bedroom”
― Robert Kushner, Primary Care:Evaluation and Management of Obesity