Early Head Start Infant Nutritional History Form - Child And Family Development Services
ADVERTISEMENT
1INFANT
L. I. Child and Family Development Services, Inc.
NUTRITION
dba: Long Island Head Start
EARLY HEAD START INFANT NUTRITIONAL HISTORY
(ADDENDUM TO PROMIS)
Early Head Start Center: ______________________________________________________
Early Head Start Center Address: _______________________________________________
Eligible Applicant: ______________________________ ________ ____________________
First
MI
Last
Number of wet diapers infant has per day:
__1-2*
__3-4
__4-5
__6+
□
□
□
□
Does child have frequent diarrhea?
Yes*
No Does child have frequent constipation?
Yes*
No
(#12)
(#13)
□
□
Is infant gaining weight steadily?
Yes
No
□
□
Has child’s weight changed by 5 lbs in past 3 months?
Yes*
No
Specify amount & time of change on referral
□
□
Is infant receiving any vitamin/mineral supplements?
Yes
No
Specify type: _________________
□
□
Food Allergies:
Yes*
No Specify: ____________________________________________________
□
□
Any problems with feeding?
Yes* (Specify on referral)
No
Any question marked with (*)
□
□
Does mother hear swallowing during feeding?
Yes
No*
Referral to Central Office Required
Specify type of formula: ________________________________________________________________
□
□
□
□
Is formula iron fortified?
Yes
No
Is infant held during feeding?
Yes
No*
□
□
Have solid foods been introduced?
Yes
No
If yes, specify which foods: ________________________________________________________
□
□
Does family ever run out of food?
Yes
No
Check off all foods that are offered to child
6-9 MONTHS
9-12 MONTHS
□
□
Breast Milk
Breast Milk
□
□
Formula
Formula
□
□
Infant cereal, Specify Type:
Infant cereal, specify type:
□
□
Fruit juice
Fruit juice
□
□
Strained vegetables
Milk or dairy products
□
□
Strained fruits
Vegetables
□
□
Strained meat
Fruit
□
□
Plain toast/teething biscuit
Meat
□
□
Other, specify:
Grains or bread products
□
Cakes, cookies, ice cream
□
Soda, iced tea
□
Other, specify:
EHS/NUTRITION-2010
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal