Food Inventory Form Check off food your child currently eats. Clinic Location Child has appointment scheduled at* Pooler Richmond Hill HiddenCurrent Date* MM slash DD slash YYYY Name of person completing form* First Last Relationship to child* Child's Name* First Last Child's Date of Birth* MM slash DD slash YYYY Texture Preference:* Crunchy Crisp Smooth Lumpy Uniform lumpy (i.e., cottage cheese) Hard Chewy Mixed Consistencies Taste Preference:* Salt Sweet Spicy Tart Flavored Bland Temperature Preference:* Hot Warm Cold Cool Appetite:*Best time of the day to eat: Overall description of appetite:* Poor Fair Good Varies from day-to-day Breads Crackers Chips Pretzels Snack mix Bugles Cheese puffs Tostitos/taco chips Taco shells (hard) Flour tortillas Rolls Pizza crusts Hamburger/hot dog buns Bread: white, wheat, rye, potato, rice, gluten-free, sourdough, pumpernickel, bagels, French bread Plain bread sticks Garlic bread sticks Texas toast/garlic bread Hot rolls, baked bread, crescent rolls, croissants Biscuits Doughnuts, sweet rolls, cinnamon rolls, caramel rolls Banana bread, pumpkin bread, apple bread, muffins Corn bread Cupcakes Cake, pies, pastries Cheesecake Cookies Others (Fill Below) Other breads* Meats Baked chicken Fried chicken Chicken strips Turkey Fish (fried) Fish (baked or broiled) Tuna Salmon Beef (steak, roast, deli-style) Roast Ribs Deer Hamburger Steak Ham Veal Pork Sausage Bacon Chicken or ham salad Tuna salad Meatballs Hot dogs Corn dogs Bologna Lunch meat Baby food meat sticks Baby food meats (Fill Below) Baby Food Meats Nuts Peanut butter (Fill Brand Below) Peanuts Walnuts Cashews Pecans Peanut butter brand Potato Products French fries Tater tots Hash browns Fried potatoes Baked potatoes Potato chips Potato wedges Shoestring potatoes Mashed potatoes (with butter) Mashed potatoes (with gravy) Scalloped/au gratin potatoes Baked sweet potatoes Candied sweet potatoes Sweet potato chips Sweet potato fries Vegetable chips Other (Fill Below) Other potato products Condiments Ketchup Mayonnaise Miracle whip Mustard Dijon or spicy mustard Honey mustard BBQ sauce A1 steak sauce Chili sauce Worcestershire sauce Ranch dressing Other salad dressing (Fill Below) Butter or margarine Chip dip Gravy Other (Fill Below) Other salad dressing Other condiments Breakfast Foods Oatmeal Cream of wheat Pop tarts Dry cereal Pancakes Waffles French toast Eggs Omelet Fried eggs Boiled eggs Poached eggs Toast Toast with butter Toast with jelly Toast with peanut butter Toast with honey Breakfast shakes Yogurt Gogurt Fresh fruit Grits Vegetables Green beans Broccoli Cauliflower Corn Squash Cucumber Zucchini Spinach Carrots Lettuce Coleslaw Cabbage Sweet potatoes Tomatoes Asparagus Brussel sprouts Green pepper Onion Peas Salsa Vegetable baby food (Fill Below) Other (Fill Below) Vegetable baby food Other vegetables Fruit Apple Banana Blueberry Cantaloupe Cherry Grapes Kiwi Lemon Lime Orange Pear Peaches Pumpkin Watermelon Raisin Raspberry Rhubarb Strawberry Tangerine Tomato Dried fruit Other (Fill Below) Other Fruits Pasta/Italian-Style Dishes Spaghetti Lasagna Spaghetti O’s/Ravioli O’s Casseroles (i.e., hamburger helper) Pizza Pizza toppings (Fill Below) Rice dishes Noodle dishes Couscous Pizza toppings Soups Cheese Cheese and broccoli Cheese and vegetables Cheaili Stew Vegetable Vegetable beef French onion Egg drop Beef noodle Chicken noodle Chicken and rice Other (Fill Below) Other soups Cheese/Dairy Cheddar American Parmesan Swiss Monterey jack Mozzarella Colby Cottage cheese Sour cream Yogurt (Fill Below) Cool whip Whipped cream Ice cream/Sherbet (Fill Below) Yogurt Ice cream/Sherbet Liquids Juice - orange Juice - cheery Juice - berry Juice - grape Juice - fruit punch Juice - strawberry Juice - strawberry-kiwi Juice - cranberry fruit cocktail Juice - white grape Juice - pear Juice - other (Fill Below) Lemonade Milk – whole, 2%, skim Flavored milk (Fill Milk types below) Soda - cola Soda - lemon-lime Soda - orange Soda - grape Soda - root beer Soda - cream soda Tea – sweetened Tea - unsweetened Milkshakes (Fill Below) Water Other (Fill Below) Other Juices Flavored milk types Soda Brands (If Any) Milkshakes Other Liquids If your child previously accepted a food item but no longer eats the food, please mention.Please list your child’s favorite foods/liquids: (Max 5) Please list your child’s least-favorite foods/liquids: (Max 5) What goal foods would you like to see your child eat with the rest of the family? (Max 5) Are there times when your child eats well?* Comments: Δ