Form DHCS4466 "Nutrition Screening Form - Food Frequency Questionaire" - California

What Is Form DHCS4466?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHCS4466 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form DHCS4466 "Nutrition Screening Form - Food Frequency Questionaire" - California

182 times
Rate (4.3 / 5) 9 votes
State of California—Health and Human Services Agency
Department of Health Care Services
Child Health and Disability Prevention (CHDP) Program
What Do You Eat? – Food Frequency Questionnaire
(Ages 8-19)
Circle the names of foods you eat often:
Office use only:
Circle to indicate the topics discussed:
Iron/Protein
Healthy eating
Chicken/Turkey
Beef
Ham/Pork
Seafood
Eggs
Tofu
Regular meals/snacks
Hot dog
Hamburger
Fried Chicken Pizza
Tacos
Importance of breakfast
Meat/Bean Burrito Pasta Spaghetti with Meatballs
Inadequate food supply
Peanut
Peanut Butter Rice
Noodle Soup
Beans/Lentils
Low fat dairy foods
Tortilla
White Bread
Whole Grain Bread
Cereal
High sugar foods
Sweet Bread
Potato
Dark Green Leafy Vegetables
Other: ___________________________
Iron/Protein
Fruits and Vegetables
2-3 servings daily
Apple
Banana
Grapes
Pear
Peach
100% Juice
High iron foods
Strawberry
Pineapple
Orange
Cantaloupe
Melon
Plant protein sources such as
Bell pepper
Chili pepper Tomato
Green Salad
Cucumber
beans, peas, lentils, nuts, etc.
Mango
Broccoli Cabbage
Dark Green Leafy Vegetables
Limit high fat foods
Carrot
Peas
Green Beans
Corn
Potato Sweet Potato
Fruits and Vegetables
2-4 fruits daily or more
Snack
3-5 vegetables daily or more
Cookies Fruit Pie
Donut
Candies
Chocolate
Vitamin C sources
Chips
Cheese Puffs
French Fries
Mexican Bread
Vitamin A sources
Calcium
Popcorn
Bagels
Pretzels
Crackers
Fruits Vegetables
3-4 servings dairy foods/day
Drinks
Nonfat or 1 % milk
Water
100% Fruit Juice
Soda
Fruit Flavored Soda
Lowfat dairy choices
Sports Drinks
Energy Drinks
Flavored Drinks
Low lactose alternative
Coffee
Coffee Drink
Tea
Sweetened Tea
Herbal Tea
Calcium fortified foods
Beer
Wine
Wine Cooler
Alcoholic Drink
Other food sources of calcium
Snacks
Calcium
High-sugar snacks
Nonfat Milk
1 % Lowfat Milk
2 % Milk
Whole Milk
High-fat snacks
Lactose Free Milk Cheese
Cottage Cheese
Yogurt
Fruit/vegetable snacks
Milkshake
Ice Cream
Calcium Fortified Soy/Plant Milk
Fast foods
Drinks
Calcium Fortified 100% Juice
Tofu
Tempeh
Soy Beans
Green Leafy Vegetables
Dried Figs Prunes
Orange
< 8-12 oz/day 100% juice
Almonds
Almond butter
Tahini
Beans
Corn Tortilla
6-8 glasses of water (8 ounces each)/day
Sweetened drinks
Name: _____________________ Age: _____ Date of Birth:
Alcohol/caffeine
_________
Referred for identified
Wt: _____ lbs Ht: _____ in BMI: _____ BMI %ile: _____ Date: ______
nutrition problem?
Yes
No
If yes, where: ______________________
Provider initials: ____________________
DHCS 4466 (05/16) Adapted from the CHDP Programs of Orange County and San Bernardino Counties
State of California—Health and Human Services Agency
Department of Health Care Services
Child Health and Disability Prevention (CHDP) Program
What Do You Eat? – Food Frequency Questionnaire
(Ages 8-19)
Circle the names of foods you eat often:
Office use only:
Circle to indicate the topics discussed:
Iron/Protein
Healthy eating
Chicken/Turkey
Beef
Ham/Pork
Seafood
Eggs
Tofu
Regular meals/snacks
Hot dog
Hamburger
Fried Chicken Pizza
Tacos
Importance of breakfast
Meat/Bean Burrito Pasta Spaghetti with Meatballs
Inadequate food supply
Peanut
Peanut Butter Rice
Noodle Soup
Beans/Lentils
Low fat dairy foods
Tortilla
White Bread
Whole Grain Bread
Cereal
High sugar foods
Sweet Bread
Potato
Dark Green Leafy Vegetables
Other: ___________________________
Iron/Protein
Fruits and Vegetables
2-3 servings daily
Apple
Banana
Grapes
Pear
Peach
100% Juice
High iron foods
Strawberry
Pineapple
Orange
Cantaloupe
Melon
Plant protein sources such as
Bell pepper
Chili pepper Tomato
Green Salad
Cucumber
beans, peas, lentils, nuts, etc.
Mango
Broccoli Cabbage
Dark Green Leafy Vegetables
Limit high fat foods
Carrot
Peas
Green Beans
Corn
Potato Sweet Potato
Fruits and Vegetables
2-4 fruits daily or more
Snack
3-5 vegetables daily or more
Cookies Fruit Pie
Donut
Candies
Chocolate
Vitamin C sources
Chips
Cheese Puffs
French Fries
Mexican Bread
Vitamin A sources
Calcium
Popcorn
Bagels
Pretzels
Crackers
Fruits Vegetables
3-4 servings dairy foods/day
Drinks
Nonfat or 1 % milk
Water
100% Fruit Juice
Soda
Fruit Flavored Soda
Lowfat dairy choices
Sports Drinks
Energy Drinks
Flavored Drinks
Low lactose alternative
Coffee
Coffee Drink
Tea
Sweetened Tea
Herbal Tea
Calcium fortified foods
Beer
Wine
Wine Cooler
Alcoholic Drink
Other food sources of calcium
Snacks
Calcium
High-sugar snacks
Nonfat Milk
1 % Lowfat Milk
2 % Milk
Whole Milk
High-fat snacks
Lactose Free Milk Cheese
Cottage Cheese
Yogurt
Fruit/vegetable snacks
Milkshake
Ice Cream
Calcium Fortified Soy/Plant Milk
Fast foods
Drinks
Calcium Fortified 100% Juice
Tofu
Tempeh
Soy Beans
Green Leafy Vegetables
Dried Figs Prunes
Orange
< 8-12 oz/day 100% juice
Almonds
Almond butter
Tahini
Beans
Corn Tortilla
6-8 glasses of water (8 ounces each)/day
Sweetened drinks
Name: _____________________ Age: _____ Date of Birth:
Alcohol/caffeine
_________
Referred for identified
Wt: _____ lbs Ht: _____ in BMI: _____ BMI %ile: _____ Date: ______
nutrition problem?
Yes
No
If yes, where: ______________________
Provider initials: ____________________
DHCS 4466 (05/16) Adapted from the CHDP Programs of Orange County and San Bernardino Counties
What Do You Eat? – Youth Nutrition and Activity Assessment
(Ages 8 - 19)
Provide additional information about your food, activity and habits:
Office use only
Complete assessment below
Eating Habits
using all information provided:
Do you eat or drink the following meals? Circle one answer per meal.
Breakfast
Always
Usually
Occasionally Never
Eating Habits
Morning snack
Always
Usually
Occasionally Never
Overall diet adequate
Yes
No
Always
Usually
Occasionally Never
Yes
No
Lunch
3 meals and snacks
Afternoon snack Always
Usually
Occasionally Never
Yes
No
High iron foods
Dinner
Always
Usually
Occasionally Never
Calcium foods
Yes
No
Evening Snack
Always
Usually
Occasionally Never
5 or more fruits/vegetables Yes
No
Yes
No
Adequate fluids
Exercise/Physical Activity
How many hours a day do you?
Exercise/Physical Activity
Watch TV
_____ hours/day
Limits use of TV, phone, internet, video or
Use a smart phone
_____ hours/day
computer games to ≤ 1-2 hours/day
Play video/computer games
_____ hours/day
Yes
No
Use the internet
_____ hours/day
Goal set:
Do you participate in physical education classes at school? Yes No
________________________
Circle all that you participate in:
Engages in physical activity
Walking
Running
Bicycling
Swimming
(60 minutes/day or more)
Yes
No
Dance
Yoga
Martial Arts
Rollerblading
Goal set: ______________________
Basketball
Softball
Soccer
Volleyball
Yes
No
Referral made
Other activities or team sports: _____________________________
Referred to: ___________________
How often are you physically active?
_____ times/week
_____ minutes/day
Weight/Body Image
BMI %ile ________ Date ____________
Weight/Body Image
 BMI between 5th and 85th %iles
Circle one. Are you trying to?
 BMI ≤ 5th %ile
Stay the same Lose weight
Gain weight
Not concerned
 BMI between 85th and 95th
Do you eat less to control your weight?
Yes
No
%iles
Explain: ________________________________________________
 BMI ≥ 95th %ile
Have you ever made yourself vomit?
Yes
No
Signs of eating disorder
Yes
No
If yes, how often? __________ When was the last time? ________
Counseling given
Yes
No
Do you ever “binge” eat?
Yes
No
Topics: _______________________
If yes, how often? __________ When was the last time? ________
Goal set: ______________________
Circle any of the following that you use:
Referral made
Yes
No
Diet pills
Laxatives
Referred to: ___________________
Multivitamins
Calcium
Iron
Vitamin D
Protein powder
Nutrition supplements
Steroids
What, if any, other products do you use?
Explain: ________________________________________________
DHCS 4466 (05/16) Adapted from the CHDP Programs of Orange County and San Bernardino Counties
Page of 2