Nutrition Practices (Breastfeeding) Tell me how it is feeding #babys#. Listen, ask, and assess for ● Hunger and satiety cues ● Number of wet/dirty diapers ● Appetite changes ● Constipation or diarrhea ● Vomiting ● Breastfeeding or formula What concerns or challenges are you having? Listen, ask, and assess for ● Frequency ● Difficulty latching on/positioning ● Weak/ineffective suck ● Fullness and engorgement ● Jaundice ● Breastfeeding support available ● Baby preferring one breast ● Baby not interested ● Breasts leaking/nipple care ● Breast pump needs/questions ● Plans for returning to work/school ● Teething/biting Has #babys# received anything other than breast milk? Listen, ask, and assess for ● Complementary foods ● Water ● Glucose (sugar) water ● Formula 1d. How often has #babys# received other foods? ● Complementary foods ● Water ● Glucose (sugar) water Age (Weeks) Or select a date 1e. How much formula has #babys# received? Age (Weeks) Or select a date 1f. What was your main reason for starting formula? 1g. What led to #babys# getting something other than breastmilk? Breastfeeding Description If bottle feeding Listen, ask, and assess for ● Amount of breast milk/formula ● Ounce/bottle and bottles/day ● Formula brand/type ● How is formula mixed ● Water source ● Contents other than breast milk/formula ● Storage/handling Does your baby take any vitamins, minerals, herbs, or dietary supplements? What other questions or concerns do you have about feeding #babys#? Or, is there anything you would like to change? ● Early introduction of solids ● Introduction of solids - types, when to start ● Developmentally appropriate foods ● Cup feeding - introduction, type, use, contents ● Making baby food ● Weaning breast/bottle Other Nutrition Risks

Nutrition Practices (Not Breastfeeding) 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 main reason for stopping breastfeeding? Has #babys# received anything other than breast milk? Listen, ask, and assess for ● Complementary foods ● Water ● Glucose (sugar) water ● Formula 2e. How often has #babys# received other foods? ● Complementary foods ● Water ● Glucose (sugar) water Age (Weeks) Or select a date 2f. How much formula has #babys# received? Age (Weeks) Or select a date Tell me how it is feeding #babys#? Listen, ask, and assess for ● Hunger and satiety cues ● Number of wet/dirty diapers ● Appetite changes ● Constipation or diarrhea ● Vomiting How do you prepare formula? Listen, ask, and assess for ● Amount of formula ● Ounces/bottle or bottles/day ● Formula brand/type ● How is formula mixed ● Water source ● Contents other than formula ● Storage/handling Does your baby take any vitamins, minerals, herbs, or dietary supplements? What other questions or concerns do you have about feeding #babys#? Or, is there anything you would like to change? Listen, ask, and assess for ● Early introduction of solids ● Introduction of solids - type, when to start ● Dietary progression ● Developmentally appropriate foods ● Cup feeding - introduction, type, use, contents ● Making baby food ● Weaning breast/bottle Other Nutrition Risks

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 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 What questions do you have regarding caring for #baby# gums and teeth?

Life Style How active is #babys# every day? Listen, ask, and assess for ● Strollers ● Play pens ● Infant seats ● Car seats Listen, ask, and assess for planned physical activity times for ● Crawling ● Rolling over ● Moving muscles (massage) ● Walking In the past seven days, has #babys# been in an enclosed space (i.e. car, home, child care) while someone used tobacco products? What else can I help you with? Listen, ask, and assess for ● Abuse/Neglect ● Limiting ability to make appropriate feeding decisions or prepare foods

Moms WIC Participation Was mother on WIC during her pregnancy? If no, would she have been eligible?