37. Please list what your child typically eats and drinks in a day for: Breakfast Lunch Dinner Snacks FAMILY 38. Check all the people that the child lives with: Mother ☐ Father ☐ Brothers (how many? ) ☐ Sisters (how many? ) ☐ Other family members (list ) ☐ Friends or other people (list ) ☐ Animals Dogs (how many? ) Cats (how many? ) ☐ ☐ ☐ Other animals ☐ 39. What medical problems do people in the family have? child’s Family Medical Problems Member Mother: Depression Anxiety (nerve) problems Learning disability ☐ ☐ ☐ Overweight High blood pressure Diabetes (sugar) ☐ ☐ ☐ Cancer Heart problems ☐ ☐ Other: Father: (nerve) problems disability ☐Depression ☐Anxiety ☐Learning blood pressure (sugar) ☐Overweight ☐High ☐Diabetes problems ☐Cancer ☐Heart Other: Sisters: Depression Anxiety (nerve) problems Learning disability ☐ ☐ ☐ Overweight High blood pressure Diabetes (sugar) ☐ ☐ ☐ Cancer Heart problems ☐ ☐ Other: Brothers: Depression Anxiety (nerve) problems Learning disability ☐ ☐ ☐ Overweight High blood pressure Diabetes (sugar) ☐ ☐ ☐ Cancer Heart problems ☐ ☐ Other:
37. Please list what your child typically eats and drinks in a day for: Breakfast Lunch Dinner Snacks FAMILY 38. Check all the people that the child lives with: ☐ Mother ☐ Father ☐ Brothers (how many? ) ☐ Sisters (how many? ) ☐ Other family members (list ) ☐ Friends or other people (list ) ☐ Animals ☐ Dogs (how many? ) ☐ Cats (how many? ) ☐ Other animals 39. What medical problems do people in the child’s family have? Family Member Medical Problems Mother: ☐ Depression ☐ Anxiety (nerve) problems ☐ Learning disability ☐ Overweight ☐ High blood pressure ☐ Diabetes (sugar) ☐ Cancer ☐ Heart problems Other: Father: ☐Depression ☐Anxiety (nerve) problems ☐Learning disability ☐Overweight ☐High blood pressure ☐Diabetes (sugar) ☐Cancer ☐Heart problems Other: Sisters: ☐ Depression ☐ Anxiety (nerve) problems ☐ Learning disability ☐ Overweight ☐ High blood pressure ☐ Diabetes (sugar) ☐ Cancer ☐ Heart problems Other: Brothers: ☐ Depression ☐ Anxiety (nerve) problems ☐ Learning disability ☐ Overweight ☐ High blood pressure ☐ Diabetes (sugar) ☐ Cancer ☐ Heart problems Other:
healthlittoolkit2-tool11b.docx