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DIETARY QUESTIONNAIRE FOR INFANTS
Pennsylvania Department of Health -- WIC Program
Infant's Name
First
Last
Endorser's Name
First
Last
Date:
MM
/
DD
/
YYYY
1. Was your baby premature?
No
Yes
If Yes, how many weeks?
Does your baby have any medical problems?
No
Yes
Please describe:
Does your baby take any medicine?
No
Yes
Please list:
2. Describe how your baby is fed:
Breastfed only
Breastfed and formula fed
Formula fed only
3. Breastfeeding mothers please answer these questions (If using formula only, proceed to question #4).
How many daytime feedings?
Nighttime feedings?
How long is each feeding?
Less than 5 min.
5-20 min.
20-30 min.
More than 30 min.
Do you have any issues with
Latch
Sore nipples
Milk supply
Fussy baby
No concerns
Other
Do you plan to return to work?
No
Not Sure
Yes
Date of Return:
MM
/
DD
/
YYYY
Full-time
Part-time
If you are using a pump, please answer these questions:
Type of pump?
Hand pump
Single Electric
Double Electric
What made you decide to pump?
How many times do you pump in 24 hours?
Ounces per session:
Does pumped milk set out (not in the refrigerator)?
No
Yes
If yes, how long?
How long is pumped milk stored in the refrigerator?
In the freezer?
How long do you keep thawed breast milk in the refrigerator?
1 day
2 dys
3 days or more
Do you re-freeze thawed breast milk?
No
Yes
How are you cleaning your breast pump?
How often?
4. If you give your baby any formula, please answer these questions:
Name of formula(s)
How many daytime feedings?
Nighttime feedings?
How many ounces per feeding?
Describe which type of formula you use and how it is prepared:
Concentrate:
ounces formula with
ounces water
Powdered:
scoops powder with
ounces water
Which is added first?
Water
Powder
Ready-to-feed: Do you add water?
No
Yes
What kind of water is used to prepare formula?
Well
Bottled
Nursery
Tap
Do you boil the water?
No
Yes
How long do you keep formula in refrigerator?
1 day
2 days
3 days or more
Not applicable
How long does a bottle of formula sit out (not in the refrigerator)?
1 hour or less
1 to 2 hours
2 or more hours
Not applicable
5. How many bowel movements does your baby have in 24 hours?
Describe the color:
Yellow/Tan
Green
Brown
Black
How many wet diapers in 24 hours?
Describe the color:
Light Yellow
Dark Yellow
Did the doctor say your baby has jaundice?
No
Not sure
Yes
6. Does your baby take any of the following?
Multivitamins
Fluoride
Iron
Vitamin D
Herbal teas or supplements
Anise Tea
None of these
Other
7. Does your baby drink from a bottle?
No
Yes
Where?
Crib
Stroller/car seat
High chair
Someone holds it
Baby walks around with it
Other
What do you do with breast milk or formula left in the bottle after a feeding?
Save it for later
Throw it away
Other
8. Does your baby use a sippy cup?
No
Yes
When?
Mealtimes
With snacks
Walks around with it
Other
What goes in the cup?
Breast milk
Formula
100% juice
Milk
Water
Other
9. Check any milk products your baby receives besides breast milk or formula:
Cow's milk:
Whole
2%
1%
Skim
Lactose-free
Chocolate/Strawberry
Goat's milk
Soy milk
Rice milk
None of these
Other
Check any other beverages you give your baby:
Soda
Kool-Aid
100% fruit juice
Hugs or drinks in pouches, boxes, etc.
Tea
Juice drinks (Hawaiian punch, Hi-C, Sunny D, etc.)
None of these
Other
10. When do you feed your baby?
When baby is fussy or cries
On a schedule
When baby seems hungry
How do you tell when baby is hungry?
How do you tell when baby is full?
11. Do you offer baby foods?
No
Yes
Which ones?
Infant Cereal
Infant fruits or vegetables
Infant meats
Other
Describe the texture:
Pureed
With chunks
How do you feed these foods?
Bottle
Spoon
Infant feeder
Do you offer table foods?
No
Yes
Describe the texture:
Pureed
Mashed
Finely chopped
Chunky chopped
Regular
12. Does your baby receive any of the following foods:
Popcorn/nuts/candy
Whole grapes
Hard candy/lollipops
Seeds/berries/raisins
Pretzels/chips
Raw vegetables
Peanut butter
Gummies/jelly beans
Hot dogs
Chunks of meat or cheese
13. Do you add salt, sugar, syrup, or honey to your baby's foods or drinks?
No
Not sure
Yes
14. Does everyone wash their hands before feeding baby and/or preparing food?
No
Not sure
Yes
15. Do you clean your baby's gums and teeth?
No
Yes
16. Check the items you have at home that work:
Running water
Stove
Refrigerator
Freezer
Microwave
Is there a thermometer in your refrigerator or freezer?
No
Yes
What is the refrigerator temperature?
Freezer?
17. Does your baby receive any of the following foods?
Raw or unpasteurized milk
Honey
Raw or uncooked eggs, meat, or fish
Soft cheese like Feta or Brie
Unpasteurized juice/cider
Bean sprouts
Raw cookie dough or cake batter
Hot dogs, deli or lunch meats
18. Does your baby drink water?
No
Yes
How many ounces daily?
19. Is your baby allergic to any foods?
No
Yes
Which foods?
20. Are others in the family allergic to any foods?
No
Yes
Who?
Parent
Sister/Brother
Grandparent
Other
What foods?
Soy
Eggs
Wheat
Peanuts/Nuts
Milk/Milk products
Other
21. Does anyone smoke in your home?
No
Yes
22. Do you ever have to choose between buying food and paying bills?
Often
Sometimes
Rarely
Never
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