Wic Health History For Infants Form - Ohio Department Of Health Page 2
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1
2If you give your baby bottles, what is in the bottles?
a
a
a
Breastmilk
Formula
Which formula? ___________________________________________
No bottles used
How many ounces a feeding? ___________________
How often are the feedings?__________________________
(38)
If you mix formula, what kind of water do you use?
a
a
a
a
a
a
Well
City
Distilled
Spring
Nursery
I don’t mix formula
a
Other _____________________________________________________________________________________
(38)
Do you have special instructions for mixing your baby’s formula from your doctor?
a
a
Yes
No
(38)
Do you have any questions about mixing your baby’s formula?
a
a
Yes
No
(38)
If you use bottles for your baby, check all that apply.
a
a
a
I wash my hands before fixing the bottle.
I reuse leftover bottles of formula.
I sterilize the bottles and nipples.
a
a
a
I wash the bottles with hot, soapy water.
I use the microwave to warm bottles.
I do not give bottles.
(38)
Other than breastmilk or formula, what else do you put into the bottle?
a
a
a
a
a
®
Karo® syrup
Juice
Punch
Cow’s milk
Jell-O
water
a
a
a
a
a
Sugar
Pop
Sheep/goat’s milk
Tea/coffee
Cereal
a
a
a
a
a
®
®
Honey
Water
Gatorade
Kool Aid
Baby foods
a
a
Other _____________________________________________________________________________
Nothing
(36, 38)
Check all that apply.
a
a
Baby is fed with a spoon
Baby uses an infant feeder
a
a
Baby drinks from a cup
Baby’s pacifier is dipped in _____________________________________________
a
a
Baby feeds self
Baby goes to bed with a bottle
a
a
Baby’s bottle is propped when feeding
Baby is usually fed away from home
(36, 38)
If your baby has started the following foods, at what age did you start
Cereal _____ Vegetables _____ Fruit _____ Juice _____ Meat _____ Dinners ______
Desserts_____ Cow’s milk _____
(36, 38)
Is there a working stove or microwave and refrigerator in your home?
a
a
Yes
No
(38)
If anyone living in your home smokes, where do they smoke?
a
a
a
a
Inside
Outside
Car
No one smokes
(46)
During the last six months, has your baby been physically, sexually or verbally abused or neglected?
a
a
Yes
No
(67)
Do you have any questions or concerns?
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