Infant Nutrition History Form Page 2
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1
2EARLY HEAD START INFANT NUTRITION HISTORY
Page 2
(Children 0-12 months of age)
Continued
Infant Name: ___________________ Center/Home Educator Name: ________________ Date: ___/___/___
TRANSITION TO SOLIDS
Date infant’s corrected age in
Assessment
Intervention
Follow
months
1
2
3
4
5
6
7
8
9
10
11
12
-Up
Acceptable
Unacceptable
(√)
Water
Plain,
Mixed with
Training &
during hot
sugar,
education
weather
honey or
Karo
Infant Cereal
Spoon fed
In a bottle,
Spoon fed,
adult cereal
infant cereal
Fruits & Vegetables
No citrus
Strained food
Spoon fed
in a bottle;
until 12
citrus before
months
12 months
Meat/Poultry/Cheese/Cottage
Spoon fed
Strained
Spoon fed
Cheese/Alternative
food in a
bottle
Bread/Cereal/Starches
Finger
Sugar-
Toast,
foods,
coated
crackers,
toast,
cereals,
Combran,
crackers,
cake,
Cheerios
Combran,
cookies
Cheerios
Juices
Infant or
Kool-aid,
Infant or
Tang, soda,
diluted
diluted adult;
iced tea;
adult. No
citrus at 12
citrus before
citrus until
months
12 months
12 months
Egg Yolk
Cooked
Egg whites;
Cooked yolk
yolk
whole eggs
Dessert/Snack
Pudding,
Candy,
Plain yogurt,
plain
chips,
fruit
yogurt
sweets
Milk
Whole milk
Nonfat or
Formula or
lowfat milk
breast milk
to 1 year
If “no”, refer
Fluoride Supplement
Yes
No
to physician
Food can be introduced
Food should not be introduced yet
Comments: _______________________________________________________________________________________
● Refer to Nutrition Coordinator if there are any concerns
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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