Nutrition/Activity Questionaire

Child’s Name
Birth Date
Height
Weight
Do you feel that your child is a good/nutritious eater?	Yes No
Is anyone in your family a vegetarian?	Yes No
Note: The USDA has established guidelines by which a child’s diet can be for adequacy.
Does your child like dairy products?	Yes No
If no, do you still encourage your child to consume dairy products?	Yes No
Note: Several national health authorities support the “5 A-Day Better Health” program which recommends eating at least five to nine servings of fruits and vegetables every day for good health.
On average, how many times per week does your child eat restaurant food (take-out/delivery; fast food and/or sit down restaurant)?
Note: Recent studies suggest there is a strong relationship between un healthy weight and frequency of eating away from home.
Do you feel that your child eats a nutritious breakfast most days of the week?	Yes No
Note: According to The American Dietetic Association, kids who don’t eat breakfast are more likely to have learning problems, be more susceptible to overweight and less likely to eat well-lanced meals and snacks overall.
How often do you encourage your child to participate in grocery shopping and/or the preparation of meals?	Frequently Occasionally Never
Note: The American Obesity Association recommends the parents involve their children in meal preparation as part of part of an overall family program to achieve a healthy body weight. This program also should include family physical activities and eating meals together as often as possible.
Do you limit or restrict your child’s consumption of sugar-sweetened beverages (juices, sodas, sport drinks)?	Yes No
Note: The American Academy of Pediatric Dentistry in conjunction with several other national health agencies recommends that children limit consumption of sugar-sweetened beverages. Fruit juice offers no nutritional benefits over whole fruit for infants older than 6 months and children. Excessive juice consumption is associated with tooth decay and overweight. Intake of fruit juice should be limited to 4 to 6 oz/d for children 1 to 6 years old. For children 7 to 18 years old, juice intake should be limited to 8 to 12 oz servings per day.
Are you familiar with Body Mass Index (BMI) as an indicator of health?	Yes No
If you would like for us to calculate your child’s BMI we will gladly do this (with a written explanation of its significance for your child).
Note: BMI is defined as Weight (kg)/Height(m) and correlates to percent body fat. The American Academy of Pediatrics recommends that children have BMI obtained on an annual basis to assure they are at a healthy weight relative to their age and gender.
On average, how many minutes/hours per day does your child engage in sedentary activities (video/computer games, TV watching, internet, telephone or non-school reading)?
Note: The American Academy of Pediatrics in conjunction with other national health organizations recommends that youths spend less than 2 hours per day engaged in sedentary activity
On average, how many minutes/hours per day does your child engage in moderate physical activity (jumping rope, bicycling, dancing, sports)?
Note: The President’s Council on Physical Fitness and Sports (PCPFS) in conjunction with several national health agencies recommends that youths engage in at least 60 minutes of moderate physical activity every day.
On average, how many hours of sleeps does your child get per night?
Note: According to the National Institute of Health (NIH), sleep, like diet and exercise, is important for normal brain and body function. Lack of sufficient and restful sleep is definitely associated with learning problems and scientific evidence suggests that adequate sleep may be necessary for optimum immunity and growth. Children ages 7-11 need 9-10 hours of sleep on a regular basis… younger children/toddlers and infants need more and older children/adolescents and teens need less.
Please give us comments and/or suggestion about how Dentistry for Children can be more helpful in promoting healthy nutrition and physical activity for you child. If you have any concerns relating to diet/nutrition and activity please feel free to discuss them with Dr. Boyd during your child’s dental appointment.

Thank You