Infant Nutrition History Form

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EARLY HEAD START INFANT NUTRITION HISTORY
(Children 0-12 months of age)
Center/Home Educator Name: ______________________________
Date:
___/____/____
Infant Name: _________________________
M
F
Birth Date : ___/____/____
EATING SKILLS
1. How do you feed your baby?:
Breastfeed
Breast and Bottle
Bottle
2. If you are breast feeding, how many times in 24 hours do you breast feed? _________________________________
Do you have any concerns about breast feeding? ____________________________________________________
3. How many ounces does your baby drink at each feeding? ______________________________________________
4. If you are bottle feeding, how many times does your baby get a bottle in 24 hours? ___________________________
How many ounces does your baby drink at each feeding? ______________________________________________
What do you use?
Concentrated Formula
Powdered Formula
Ready to Feed
Fresh Milk
How do you prepare your formula? ___________________________________________ Blend: _______________
5. Do you put your baby to bed with a bottle?
Yes
No
6. What else do you put in your baby’s bottle?
□ Water
□ Water w/Sugar
□ Honey
□ Karo Syrup
□ Jello Water
□ Rice Water
□ 100% Juice
□ Cereal
□ Hi-C
□ Lemonade
□ Punch
□ Kool Aid
□ Soda
□ Tea
□ Coffee □ Chocolate Milk
□ Sport Drink (Gatorade)
□ Homemade Baby Food
□ Baby Food in Jars
□ Bottle Only
7. Which do you feed your baby?
8. Who else feeds your baby? ______________________________________________________________________
□ Diarrhea
□ Constipation
□ None of these
9. My baby has:
Allergies _____________________
□ Yes
□ No
10. Do you have any questions about the way your baby is eating?
If “Yes”, please explain: ________________________________________________________________________
___________________________________________________________________________________________
ASSESSMENT
Age/Weight
Nutritional Intake
Assessment
Intervention
Follow-up
(√)
Breast Feeding
Nurse on demand?
Y N
If less than recommended,
Nurse at least 8x/day?
Y N
evaluate growth grid WNL. Refer
(First month)
to lactation consultant if
Nurse at least 5x/day?
necessary.
(After first month)
Y N
8 lbs.
20-23 oz. Formula
Complete bottle in 20-30
>30 minutes-evaluate suck-
minutes?
Y N
swallow
Holds baby while feeding? Y N
Encourages/demo holding
Y N
Correct mixing of formula
Is formula mixed correctly?
12 lbs.
28-32 oz. Formula
Complete bottle in 20-30
>30 minutes-evaluate suck-
minutes?
Y N
swallow
Holds baby while feeding?
Encourages/demo holding
Is formula mixed correctly?
Correct mixing of formula
4 to 6 months
30-32 oz. +strained foods
Hold head upright?
Y N
Start solids
Food stays in mouth?
Y N
7 to 9 months
22-28 oz. +junior foods
Picks up small objects?
Y N
Start finger feeding
Holds own bottle?
Y N
Examples: Cheerios, crackers
and toast
10 to 12
22-28 oz. + junior foods
Drinks from cup?
Y N
Encourage self-feeding
months
+ table food
Eats lumpy food?
Y N
Introduce table foods/textures
Pink – Parent
Blue – Health File
White – Child’s File
Distribution:
Revised 8/15
H/N Services G:\Master Forms\01 Numbered Forms Word Only\437 EHS Infant Nutrition History NCR (ES).rtf

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