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 Tell me about #babys#'s 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 ● Limited ability to make appropriate feeding decisions or prepare foods