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Diet Health History for Infants
Source: www.dshs.state.tx.us
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Short Description: Diet Health History. for Infants. Breastfeeding History for Infants. Is this infant currently breastfed? 1. qYes. q No. If no,was this infant ...
Content Inside: Diet Health History Today's Date: _________________ Name: ______________________ for Infants DOB: _________ Age: _________ Breastfeeding History for Infants 1. Is this infant currently breastfed? q Yes q No 18. How are bottles and equipment cleaned? ____________________ 2. If no, was this infant ever breastfed or fed breastmilk? q Yes q No ________________________________________________ Breastfed Infant (Total or Partial) 19. How are bottles of breastmilk or prepared formula stored? 3. How many feedings has this infant had in the past 24 hours? ______ ________________________________________________ 4. How long did each feeding last? __________________________ All Infants 5. Have you had any problems breastfeeding? 20. Do you always hold this infant during feedings? q Yes q No q Yes q No If yes, list the problems: ________________________________ 21. Do you put this infant in bed with a bottle? q Yes q No ________________________________________________ 22. Do you prop up the bottle? 6. How many dirty diapers per day? _________________________ q Yes q No Bottle-Fed Infant (Answer only if bottle-feeding this infant.) 23. Do you let this infant crawl or walk around with the bottle or a cup? q 7. What type of formula do you use for this infant? Yes q No q Powder q Concentrated q Ready-to-Use 24. Do you give this infant the bottle whenever he cries? q 8. What is the name of the formula? _________________________ Yes q No 9. How is the formula diluted and mixed? 25. Do you give the bottle to feed liquids other than breastmilk, formula, or water? ________________________________________________ q Yes q No 10. Do you add anything to the formula besides water? If yes, what do you give? _______________________________ q Yes q No 26. Have you ever given this infant any drinks other than breastmilk If yes, what is added? __________________________________ or formula? q Yes q No 11. Is water boiled before it is mixed with formula? q Yes q No If yes, how old was the infant? ___________________________ 12. How many bottles do you make at one time? _________________ 27. Do you give any of the following to this infant? a. juice q Yes q No 13. How much breastmilk or formula do you put in each bottle? _______ b. water q Yes q No 14. How much breastmilk or formula does this infant drink at each c. tea or coffee q Yes q No feeding? __________________________________________ d. colas or other sweetened beverages q Yes q No e. corn syrup, sugar, or salt q Yes q No 15. How many bottles of breastmilk or formula does this infant drink f. honey q Yes q No in 24 hours? ________________________________________ 28. Have you ever given this infant any foods other than breastmilk or 16. How long does one can of formula last? _____________________ formula? 17. What is done with leftover breastmilk or formula in the bottle? If yes, at what age? ___________________________________ ________________________________________________ If no, skip to Health History for Infants. Continue on other side
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