Health/Medical
What concerns do you have about #baby# health?
Does #babys# have any medical problems diagnosed by a doctor?
Medical Conditions
Is #babys# currently on any medication?
Listen, ask, and assess for
● Medications that compromise nutritional status
Biological Mother
BioMotherHtWt
lbs
in
Biological Father
lbs
in
Immunizations
Can we look over #baby# shot record today?
Have any DTaP shots been given?
# of DTaP immunizations
Oral Health
How do you take care of #baby# teeth?
Has #babys# seen a dentist?
Life Style
What types of activities does #babys# enjoy?
# of hours of TV watching/video playing per day
In the past seven days, has #babys# been in an enclosed space (i.e. car, home, child care) while someone used tobacco products?
Nutrition Practices
Breastfeeding Description
How old was #babys# when he/she completely stopped breastfeeding or being fed breast milk?
Age (Weeks)
Or select a date
What was your reason for stopping breastfeeding?
Has #babys# received anything other than breast milk?
Listen, ask, and assess for
● Complementary foods
● Water
● Glucose (sugar) water
● Formula
5e. How often has #babys# received other foods?
● Complementary foods
● Water
● Glucose (sugar) water
Age (Weeks)
Or select a date
5f. How much Formula has #babys# received?
Age (Weeks)
Or select a date
Tell me about #babys# eating and what he/she likes to drink.
Listen, ask, and assess for
● Appetite
● Eating pattern
● Frequency
● Eating problems
● Beverages/containers
● Food preparation
● Food jags/refusal
What is mealtime like?
Listen, ask, and assess for
● Environment
● Tone of mealtime
● When, where, with whom?
Is there anything you would like to see different about #baby# eating?
Are there any foods you would like to see #babys# eat more/less of?
Does #babys# take any vitamins, minerals, herbs, or dietary supplements?
Other Nutrition Risks
Social Environment
What else can I help you with?
Listen, ask, and assess for
● Abuse/neglect in the last 6 months
● Limited ability to make appropriate feeding decisions or prepare foods