Alaska Program Infant Application Page 2
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1
2Infant Application
33.
How old was your baby the first time he or she drank
liquids other than breastmilk or formula?
20.
On a scale of 0 to 10, how is breastfeeding going?
411.1
Not Well 0 1 2 3 4 5 6 7 8
9 10 Very Well
My baby was ______ months.
I breastfeed _____times in 24 hours. 411.7, 603, 702
List what he or she drank: ______________________
Each feeding lasts ________ minutes.
603,
___________________________________________
702
34.
How old was your baby the first time he or she ate food
My baby has ____ (#) stool diapers a day.
411.7
such as cereal, baby food, or any other food?
My baby has ____ (#) wet diapers a day.
My baby was ______ months.
411.3
411.7
21.
Are you breastfeeding another child?
No
Yes
List what he or she ate:_________________________
22.
How do you store breastmilk? (i.e., freeze, refrigerate,
____________________________________________
store on counter, in cabinet, etc.)
35.
Is your baby held when bottle fed?
381,
______________________________________ 411.9
411.2
23.
What do you usually do, if there is leftover breastmilk or
Never
Rarely
Sometimes
Always
formula in the bottle after a feeding?
411.9
36.
Where else do you give your baby a bottle?
Throw it out
Put in refrigerator
Crib/Bed
Car Seat
High-chair
Stroller
Leave near baby
Other_________________________________411.2
If Formula Feeding
37.
How do you feed your baby solid foods?
411.2, 411.4
24.
If you ever breastfed, on what date did breastfeeding end?
No solid foods, only breastmilk/formula
_______________________________________________
by Spoon
In Baby Bottle
by Infant Feeder
25.
What was the reason that breastfeeding was stopped?
Baby foods
Finger foods
Other __________
_______________________________________________
38.
Check the foods your baby eats?
411.4, 411.5,
26.
At what age did you start your baby on formula?
411.8
I started my baby on baby formula at the age
No solid foods, only breastmilk/formula
of _____ days or _____ weeks.
Infant Cereal
Infant Cereal in the bottle
701
Homemade baby food
Crackers
On a scale of 0 to 10, how is formula feeding going?
Chopped fruits/vegetables
Bread
Not Well 0 1 2 3 4 5 6 7 8
9 10 Very Well
Strained or mashed vegetables or fruits
Strained meat/egg yolk/yogurt/cottage cheese/tuna
27.
What formula are you feeding your baby?
_________________________________________
Cooked soft pieces of beans/chicken/turkey/beef/
pork
28.
How often do you feed your baby formula?
_________________________________________
Raw or undercooked meat, poultry, fish, eggs
29.
How much formula does your baby eat at a feeding?
Unheated hot dogs/deli meat or poultry
_________________________________________
Soft cheeses made with un-pasteurized milk: Feta,
How do you prepare your baby’s formula? 411.5, 411.6
30.
Mexican style (queso blanco fresco), Brie, Blue
Powdered formula
Raw sprouts (alfalfa, clover and radish)
I add ___ scoops of powder to ____ounces water
Un-pasteurized milk, fruit or vegetable juice or
Concentrated formula
foods made with Un-pasteurized milk
I add ___ounces concentrate to ____ ounces water
Ready-to-feed formula
39.
How do you know your baby is done eating?
411.4
Do you add water?
No
Yes _____oz
Won’t open his/her mouth
Turns head away
31.
Does your baby drink juice, sweetened drinks, soda, sweet
Eats all food
Bottle is empty
Spits out food
tea, Tang/Koolaid or Hi-C in a bottle or a cup?
40.
What does your family do for fun?
Yes
No
Sometimes 411.2,
_________________________________
411.3
Do you add sugar, honey or syrup to your baby’s pacifier
32.
41.
For Dads - please tell us what your weight ___________
or foods?
and height ____________ are.
Yes
No
Sometimes
411.3
42.
How can WIC help your family today?
If yes, tell us more about the reasons:
_______________________________________________
__________________________________________
_______________________________________________
Thank you!
Rev 9/ Infant Application
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