1.
How many glasses of water do you drink daily?
8 or more
6-8 glasses
less than 6 glasses
2.
How many cups of tea or coffee do you drink daily?
4 or less or none
4-5
6 or more
3.
How many alcoholic beverages do you consume on average per week?
0-1
1-3
more than 3
4.
Are you taking a multi-vitamin supplement?
yes, everyday
almost everyday
seldom or never
5.
How often do you consume the following calcium containing foods?
Milk (cows or soya)
at least 2 cups a day (in tea, cereal etc.)
at least 1 glass a day
rarely, or never
6.
Yoghurt (175ml)
at least 1 a day
1 every other day
seldom or never
7.
cheese (such as a hard cheddar )
1 matchbox serving daily
1 serving every other day
seldom or never
8.
salmon/pilchards with bones, green leavy vegetables such as spinach, or tofu
3 times a week
1-2 times a week
seldom or never
9.
If you do not eat dairy at all, do you take a calcium supplement?
I eat plenty of calcium containing foods or I take a calcium supplement
I sometimes take a calcium supplement to supplement my diet
I don’t eat much dairy and I don’t supplement my diet with calcium
10.
Does your Body Mass Index (BMI) fall within the normal range?
BMI = weight/(height x height)
Normal = 19-26
yes
no
11.
Would you regard your eating pattern and habits as healthy?
yes
sometimes
no
12.
Do you try and eat 3 regular meals or 6 smaller nutritious snacks during the day?
always or mostly
sometimes
seldom or never
13.
Do you eat at least 5 different servings of fruit and vegetables during the day?
always
most days
seldom or never
14.
Do you eat at least 1 serving of protein during the day?
1 serving = 1 chicken breast/piece of fish/palm size red meat/1 cup lentils or beans/ 1large egg
at least 1 serving daily
most days at least 1 serving
seldom eat protein
15.
How often do you exercise? 1 session = 30-45 minutes
3 times a week
1-2 times a week
seldom or never
16.
If food allergies are common in you or your husband’s family, are you trying to exclude the common foods while breastfeeding? E.g. peanuts
no allergies, or yes I am excluding allergy prone foods
may be allergies in family and sometimes try to exclude allergy prone foods
although may be a history of allergies, not avoiding any foods
17.
Do you find that certain foods you eat affect your baby? E.g. colic or cramps when eat onions and cabbage? If yes do you
exclude the offending foods from your diet, or no symptoms
not sure if symptoms are related
treat the symptoms, and continue to eat ‘offending’ foods
18.
Are you exclusively breastfeeding? I.E. not supplementing baby’s feeds with formula milk, juice or water (if younger than 6 months of age)
yes, I am exclusively breastfeeding or child is older than 6 months of age
mostly exclusive, express milk into bottles when necessary
no, not exclusively breastfeeding
19.
How long are you planning to breastfeed for?
at least 1 year if I can
at least for 6 months
less than 6 months
20.
Do you have your child weighed on a regular basis at the doctor or clinic?
yes
sometimes
seldom
21.
Is your child growing according to his/her growth chart growth curve?
yes
unsure
no
22.
Do you smoke?
never
less than 2 a day, and always away from my child
more than 2 a day
