Baby'S Diet Health Questionnaire Form - Wic Oregon printable pdf download

Baby'S Diet Health Questionnaire Form - Wic Oregon

Your baby’s diet questions

Infant’s name:

Today’s date:

Please answer these questions about your baby.

1. How are you feeding your baby?

 B reastfeeding

 Breastfeeding and formula feeding

 F ormula feeding

2. If your baby only drinks breast milk:

a. How often does your baby breastfeed in 24 hours?

b. Is your baby breastfeeding as often as he or she wants?

 Y es

 No

3. If your baby drinks both breast milk and formula:

a. How often does your baby breastfeed in 24 hours?

b. At what age did you start giving formula to your baby?

4. If your baby only drinks formula:

a. How long did you breastfeed?

b. At what age did you start giving formula to your baby?

5. If your baby uses a bottle:

a. What does your baby usually drink from the bottle? (check all that apply)

 B reast milk

 W ater

 S weetened drinks (pop, Kool-Aid®)

 F ormula

 F ruit juice

 C ereal

 O ther:

b. Does your baby fall asleep with the bottle at nap or bedtime?

 Y es

 No

OVER 

57-622 ENGL (7/2015)

Baby'S Diet Health Questionnaire Form - Wic Oregon