DIETARY QUESTIONNAIRE FOR INFANTS
Pennsylvania Department of Health -- WIC Program
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  • 3. Breastfeeding mothers please answer these questions (If using formula only, proceed to question #4).

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  • If you are using a pump, please answer these questions:

  • 4. If you give your baby any formula, please answer these questions:

  • Describe which type of formula you use and how it is prepared:

  • Concentrate:

  • Powdered:

  • 9. Check any milk products your baby receives besides breast milk or formula:

H511.866 (Rev.5/16)