Dietary Questionnaire and Guidance


Kansas WIC Program Banner

The Kansas WIC Program uses diet questionnaires to assess the dietary/feeding practices of WIC applicants. This enables WIC staff to assign applicable risk factors and determine appropriate referrals, counseling and food package tailoring needs. All WIC applicants complete an age and categorically appropriate Diet Questionnaire at certification.

WIC clinics should copy Diet Questionnaires using the following color guide:

Prenatal - Yellow paper
Postpartum - Blue paper
Young Infant (0-6 months) - Green paper
Toddler (6-24 months) - Purple paper
Child (2-5 years) - Orange or Peach paper

The guidance documents review the risk factors that are assessed by each question on the corresponding Diet Questionnaire. Refer to the Nutritional Risk Factor manual for the complete definition for each risk factor.

Note: The State Agency asks that if a Local Agency wants to use Diet Questionnaires as fillable forms that they email their state Nutritionist a plan that includes the process (including how you will handle clients that don’t complete the forms online or by fillable form, etc.) Please include how you will safely store and easily retrieve the DQs long-term, whether printed on paper and physically stored, or electronically stored.
TIP: Recommend opening fillable forms in Chrome.

Click on the links below to download diet questionnaire and guidance materials

Prenatal

Prenatal Diet Questionnaire

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Prenatal English – Fillable Form (new!)

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Prenatal Diet Questionnaire (Spanish)

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Prenatal Spanish – Fillable Form (new!)

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Prenatal Guidance


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Postpartum

Postpartum Diet Questionnaire

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Postpartum English – Fillable Form (new!)

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Postpartum Diet Questionnaire (Spanish)

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Postpartum Spanish – Fillable Form (new!)

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Postpartum Guidance


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Young Infant

Young Infant Diet Questionnaire

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Infant 0-6 mos English – Fillable Form (new!)

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Young Infant Diet Questionnaire (Spanish)

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Infant 0-6 mos Spanish – Fillable Form (new!)

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Young Infant Guidance


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Toddler

Toddler Diet Questionnaire

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Toddler English – Fillable Form (new!)

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Toddler Diet Questionnaire (Spanish)

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Toddler Spanish – Fillable Form (new!)

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Toddler Guidance

(Toddler fillable forms are not available at this time)

Child

Child Diet Questionnaire

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Child 2-5 English – Fillable Form (new!)

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Child Diet Questionnaire (Spanish)

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Child 2-5 Spanish – Fillable Form (new!)

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Child Guidance


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