Baby / Child Nutrition Questions (6-23 Months) - California Health And Human Services Agency
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1State of California—Health and Human Services Agency
Department of Health Services
WIC Supplemental Nutrition Branch
BABY / CHILD NUTRITION QUESTIONS (6–23 months)
Baby’s / Child’s Name:
Baby’s / Child’s Age:
Please circle or write your answers to the following questions:
1. What month is your baby’s / child’s next doctor’s appointment?
2. How do you know when your baby / child is ready to eat?
How do you know when your baby / child is full?
3. If you breastfeed your baby / child:
How many times in 24 hours do you breastfeed?
How is breastfeeding going? (not good) 1 ............. 2 ............. 3 ............. 4 ............. 5 (great)
4. If you feed your baby / child formula:
How often does your baby / child take a bottle of formula?
How many ounces of formula does your baby / child drink at a feeding?
What brand of formula do you give your baby / child?
Explain how you make the formula.
How is formula feeding going? (not good) 1 ............. 2 ............. 3 ............. 4 ............. 5 (great)
5. If your baby or child uses a bottle or a cup:
♦
Where are all the places your baby / child takes a bottle or a cup? Bed
Stroller
Car Seat
Held in someone’s arms
High-Chair
Holds his/her own bottle
Other (list)
♦
What does your baby/child drink from a bottle or a cup?
Water
Rice Water
Hi-C / Punch
Coffee
Breastmilk
Water with Sugar
Cereal
Soda
Tea
Formula
Water with Honey
Skim Milk
Lemonade
Manzanilla / Chamomile Tea
Water with Karo Syrup
Lowfat Milk
Juice
Pedialyte
Jell-O Water
Whole Milk
Gatorade
Other
6. What do you feed your baby / child?
Family / Table Food
Baby Food in Jars
Both
None
7. Which textures of food do you feed your baby or child?
Pureed
Chunky
Chopped
Soft Pieces
Other
8. What foods does your baby / child eat?
Cold / Hot Cereal
Beef / Chicken / Fish
Fruits
Yogurt
Crackers
Rice
Eggs Yolks Whites
Vegetables
Ice Cream
Candy
Noodles / Spaghetti
Peanut Butter
Beans
Pudding / Custard
Nuts
Tortillas
Meat Sticks
Soup
Popsicles
Popcorn
Bread / Toast
Hotdogs
Cheese
Raisins
Cookies
French Fries
Chips
Tofu
Other (list)
Honey
9. My baby/child uses the following:
Breast
Bottle
Cup
Spoon
Fork
Fingers
10. I give my baby / child:
Vitamins
Fluoride
Iron Drops
Medicine
None
Other
11. My baby / child currently has: Allergies
Wheezing
Rash
Constipation
Diarrhea
None
12. Has your child had a blood lead test?
Yes
No
If yes, when?
13. What questions do you have about your baby’s / child’s eating and growth?
For Staff Use Only
Date:
WIC Staff Name:
Participant WIC ID #:
Length / Height:
Weight:
WIC is an Equal Opportunity Program
DHS (ENG) (09/05)
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