Dietary Questionnaire & Guidance

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 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 to 6 months) - Green paper
  • Toddler (6 to 24 months) - Purple paper
  • Child (2 to 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.

Links for Diet Questionnaire & Guidance Materials

Prenatal

Postpartum

Young Infant

Toddler

(Toddler fillable forms are not available at this time)

Child