< MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES D, WiC AND NUTTIN SERVICES / NUTRITION ASSESSMENT FOR INFANTS Ee COMETS Form completed by: L] ParenvGuardian or wic Staf: LlcpA [imp Cl Nutitionist [1 wic Certifier Please think about your baby's eating pattern and answer the following questions to the best of your abil Place a check mark in the box & andlor weite-in your answer, 4._How would you describe your baby’s appetite? _L]Good _L] Fair L] Poor 2. Have you noticed any recent changes in your baby's appetto? i yes, st changes: = : Has the doctor ever told you tha your baby has any medical condions or Hnesses? [940] ives it ee [When was tho lal tine your baby went othe doctor? Dale How would you deserbofeoding te with your baby? Check al hat apDy Clamays pleasant [Usually plessant Ll Sometimes pleasant CJ Novor pleasant [What ypes of tings can your baby do? Check all that apply. [428) open mourn fortreastorborio LI brn iquds C1 Skwih support Bring objects to mouth and bite them EBV Sey Gifs tas ss um open = laa hae Wai CTU a t= CV ca Wie 7. How many wet diapers does your baby have in 24 hours? — wet/24 hours meee '8._How many dirty diapers does your baby have in 24 hours? ___dirly/24 hours: Fw yp of mec you fed your bay? Chek a toy Ciereastmik iromfortied formula] Low-ron formula I Cow's mi at tree/skim; 1%, 2% or whole) Trice mix or Soy mik Beverage El Powdered milk] Evaporated milk C] Sweetened condensed mi Coat’ mk Ti Dont know Cotter 16, Are you cureiy breastfeeding yourbaby? Ez Tons LT ves CN] 1, Did you ever breastfeed your baby? ; aS Yes ETN ityes, how long? se 12. How do you know when your baby is hungry? Check all that apply. [411.4] [icties Ci Small fussing sounds C1 Sucking on hands ors (1 Tums head towards ripple or botte _(l Other: 18. How do you Krow when your baby is Tu? check all thal apply. 611.4] [closes mouth C1 Turns head away from nipple or bole] Pushes nipple ou of mouth in other things in room Other 14, How is brestfeeding going? [603] [Good tnavo tho holp mead. 1 OK; have some questions. _ C1 Not so good need hep. 16, How many times do you nurse, express or pump in 24 hours? [414.7] Nurse tmesi24 hours Express. tmes/24 hours Pump —__imos/24 hours 16, Have you over experienced soreniples? [603]... ae (yes No] 417, Can you haar your baby swallowing during feed : _LHives. HANDLING EXPRESSED OR PUMPED SREASTWILK 18. How do you stor expressed breastmilk? Freezer [) Religerator (1 Other i9]] 18. How long do you Keepin te retgeraor Defoe you vow R-away’? hours or aya (Gil ond] (att 9) '20. How long do you keep breastmilk afer it's thawed? hours or days (Circle one) ATS] i. What do you do with breastmik left in the bottle? C Leave it out to feed tater__LI Put it back into refrigerator for later ETc) 22. What kind of formula is your baby taking? Name: (34a]] UiPowder U1 Liquid Concentrate C1 Ready to feed [41.9] Throw it away (Other: 23. How many ounces of formula does your baby take ata feeding?” —— ounces pe Tesding And, how many feadings por day? feedings/24 hours (RMCNGRORMEA Se ee Pa OT '24. How much water and formula do you mx perfeoding? —__ ounces of water with ounces or s200ps of formula (Circle one) Are the scoops of formula level or heaping? Heeping Otel How do you store formula ater you mixit up? C1 Reigerator Bother: THETATON ASSESOHENT FOR TENTS TRGETOFE wer ‘TURNPAGE OVER TO COUPLETE) Nowra[25. How long do you keep mixed formula in the refrigerator belore you throw it away? hours or days (Circle one) (411.9) '26. How long do you leta bottio of formula sit at room temperature? ___ hours [att 27. What do you do with formula leftin a botle after a feeding? tari] CD Leave it out to feed tater Put it back in refrigerator to feed later. C1 Throw itaway C1 Other: WATER SUPPLY '28. What kind of water do you use for mixing formula or drinking for your baby? [411.9] Clery or rural water system LI Private we] Bottled water] Nursery Wator 4: I privat wel, has i been tested for bacteria or nitrates? cvsED¥es EINo C1 Don'tknow | "yee. check resuts: LI Safe] Unsafe LI Dont know |.__b.Do you know if your water is fluoridated? : : Dyes No C1 Don'tknow 29. Has your baby started on infant cereal, baby food or table food? [411.2] [411.3] [411.4] [428] Olves CNo if yes, at what age oid you start feeding these foods and what foods? : " ‘re they most: CI Mashed [1 Pureed or Baby foods [1Cropped Cluiqua Cl ringertooas 1 otner If yes, how do you feed these foods? [1 Spoon [-]Botlefinfant feeder [1 Baby feeds sel 720. Does your baby eat honey of any foods made wih honey such as honey graham crackers, mufin, 131. Does your baby drink 100% frit juice? ‘ouncosiday Ifyes, how many ounces ot full strength juices in a day? |32._How do you feed juice to your baby? _[_] Battle] Cup [411.2] 33.At what age did you bogit Teed juice to your baby? months fait} /*34, Does your baby eat foods such as: (411.5) @. unpasteurized fr or vegetable juces or dary produts : ee yes Lino b soft cheeses such as Feta, Brie, Camembert, blue-vined cheese, Mexican-siye cheese Dyes Ono ©. raw or undercooked meats, fish, chicken, turkey or eggs : oe Dyes Ono 4. raw vegetabie sprouts (aia, clover, bean, fadsh) oes sss vessesecversestyeeseeseierese sess Yes EDNo ©, uncooked luncheon meats, del meats, hot dogs... os. Se yes No 2.1 your baby on a special dict? [411.8 940] ves One ifyes, check or witesn what kind C1 Vegan Macrobiotic] Other: |35. Does your baby routinely eat sweet foods like lollipops, candy, sweetened cereals, or desserts? [428] OyYes CiNo ltem(s) & Amouni(s) PESTS 57. Does yur baby irk anyting ae an beastie frmua ina baby bate or spy op? F412 411-3 (yes (No if yes, check al that apply.) Mik TT ice (10026) “IWater C1 Soft arinkstsodalpop “__FGoiatin waterrcoot-Aid _ Sweetened toa Botner 736, Do vou dip your baby’s pacifier in Karofoom syrup or honey oF adG ito your baby's botie? [411.2 411.3 411.5] Ives —LINo =39. Does your baby take bottle to bed at night or naptime? [411.2] Cyes CINo 40. Do you hold your baby’s botle while feeding himher? [411.2] yes CINo “41_Does your baby cary a bot oF sippy cup around? [411.2 : Tes CI No SUE 42, Does your baby take any vitamins, minerals, herbs or herbal supplements? [411.10 411.11 -Dyes Ono yes, check all that apply, LI Infant multivitamin [Vitamin D Supplement 5 Herbal supplements, remedies or teas Tiron supplement___L Fluoride supplement D other: AO 43. In the past month, did you or anyone in your household ever eat fess than you felt youthey should or not eat F a whole day because! there wasnt enough money for food? Clyes C1No C1 Dont know or reised 4 nthe past month, you ran out of formula what id you do Lit }45, Does your baby or family participate in any of the following programs? Oves OCINo ifyes, which ones? Food Stamps | Family Nutrition Education Program (FNEP) Commodity program Food Pantry © Early Head Start (Ol Parents as Teachers [7] Other: 45. Do you have adequate equioment for food storage and preparation such as a refrigerator, a stove that works, and storage free from pests| ‘and harmful chemicals? [411.9] O yes CNo NosmanT(30 TUTATIEN ASSESSMENT FoR RANTS THGEZOF® Wor