Suidi Reporting Form - Sudden Unexplained Infant Death Investigation Page 5
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8INFANT DIETARY HISTORY
1
On what day and at what approximate time was the infant last fed?
:
/
/
Month
Day
Year
Military
Time
2
What is the name of the person who last fed the infant? ______________________________________________________________
3
What is his/her relationship to the infant? __________________________________________________________________________
4
What foods and liquids was the infant fed in the last 24 hours (include last fed)?
Unknown No
Yes
Quantity
Specify: (type and brand if applicable)
a) Breast milk (one/both sides, length of time)
ounces
b) Formula (brand, water source - ex. Similac, tap water)
ounces
c) Cow’s milk
ounces
d) Water (brand, bottled, tap, well)
ounces
e) Other liquids (teas, juices)
ounces
f) Solids
g) Other
5
Was a new food introduced in the 24 hours prior to his/her death?
No
Yes
Describe (ex. content, amount, change in formula, introduction of solids)
6
Was the infant last placed to sleep with a bottle?
Yes
No
Skip to question 9 below
7
Was the bottle propped?
(i.e., object used to hold bottle while infant feeds)
No
Yes
What object was used to prop the bottle? ______________________________________________________
8
What was the quantity of liquid (in ounces) in the bottle? ____________________________________________________________
9
Did death occur during?
Breast-feeding
Bottle-feeding
Eating solid foods
Not during feeding
10
Are there any factors, circumstances, or environmental concerns that may have impacted the infant that have not yet
been identifi ed?
(ex. exposed to cigarette smoke or fumes at someone else’s home, infant unusually heavy, placed with positional
supports or wedges)
No
Yes
Discribe concerns: _________________________________________________________________________
PREGNANCY HISTORY
1
Information about the infant’s birth mother:
________________________________________
Middle name ____________________________________________
First name
________________________________________
Maiden name ___________________________________________
Last name
__________ - _____ - __________
Date of birth:
______/ ______ / ________
SS #
Month
Day
Year
Current Address ____________________________________
City _________________________
________________
State
ZIP
Previous
_________
and _________
Address
______ _________
How long has the birth mother been a resident at this address?
Years
Months
City
State
2
At how many weeks or months did the birth mother begin prenatal care?
___________ Months
Weeks
No prenatal care
Unknown
3
Where did the birth mother receive prenatal care?
(Please specify physician or other health care provider name and address.)
Physician/provider ________________________ Hospital/clinic _____________________________ Phone ( ____ ) _____-___________
Street __________________________________________ City _______________________ State _________ ZIP ________________
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