Nutrition History & Assessment: Infants and Toddlers

Applicant’s Last, First Middle Name: ____________________________ DOB: __________ Male Female

HISTORY

1. Do you currently breast feed your child? Yes No How often? ___________ times/ 24 hrs.2. Is your child currently drinking from a bottle: Yes No How often? __________ times/ 24 hrs.3. What does your child drink from a bottle? ____________________________________________________________4. Do you currently feed your child formula? Yes No How much per feeding ____________ oz/bottle.5. Has your child been diagnosed with colic? Yes No 6. Has your child been diagnosed with reflux? Yes No7. Is your child currently using a cup? Yes No What kind? (Sippy cup, regular glass, etc.) _______________8. Is your child currently feeding himself? Yes No Describe: _________________________________________9. Is your child currently taking a vitamin/mineral supplement? Yes No10. Is your child taking a prescribed iron supplement? Yes No 11. Do you give your child cow milk? Yes No What kind? (whole, nonfat, 2%, 1%, nonfat, lactose free, chocolate,

almond, etc.) _____________________________________________________________________________________________

12. Does your child eat baby food? Yes No What kind? ______________________________________________13. Does your child eat solids? Yes No Which of these foods do you offer your child?

Baby Cereal What kind? _____________________________________________________________________ Juice What kind? _____________________________________________________________________ Eggs, Beef, Poultry, Fish Pork, Beans Vegetables Rice, Bread, Cereal, Potatoes Fruit

14. Which of the above food group(s) are consumed more frequently? ______________________________________________________________________________________________________________________________________

15. Does your child have any chewing or swallowing difficulties? Yes No Describe: _____________________________________________________________________________________________________________________

16. Any known food allergies or intolerances? Yes No Describe: ____________________________________________________________________________________________________________________________________

17. Does your child have any known special diet needs? Yes No Describe: ______________________________18. Is your child currently on WIC? Yes No Where? ________________________________________________19. Is your child/family currently on SNAP (food stamps)? Yes No20. What questions or health concerns do you have about what your child eats, doesn’t eat, the quantity eaten, the child’s

weight or the child’s growth? __________________________________________________________________________________________________________________________________________________________________Have you discussed those concerns with your WIC provider or doctor? Yes No What did they tell you? _____________________________________________________________________________________________

-OVER-

Health/Dental/ Nutrition #22 Original to file 01/25/18

Nutrition History & Assessment: Infants and Toddlers

Bottle Offer: Oferta de biberón21. Seedlings will also offer and provide the following feeding bottles for infants 1 year and younger. Seedlings también ofrecerá y

proporcionará los siguientes biberones para bebés de 1 año o menos.Please circle bottle you want your child to receive while in our program / Por favor, circule el biberón que desea que su hijo reciba mientras está en nuestro programa.

Angel of Mine

Evenflo Silicone Anatomic nipple (Medium flow)

Evenflo Feeding Classic Twist Tinted bottles

Other

If it appears your child is having difficulty in using any of the bottles listed above, teaching staff will discuss this with you, to find a bottle that works for your child. - Si parece que su hijo tiene dificultad en usar cualquiera de las botellas mencionadas arriba, el personal de enseñanza discutirá esto con usted, para encontrar un biberón que trabaje para su hijo.

If infant requires specific bottle and nipple due to a medical reason, Seedlings will provide at no cost to parent. Proper documentation will be required and approved by USDA and Health Specialist. -Si el bebé requiere botella y pezón específicos debido a una razón médica, Seedlings proporcionará sin costo a los padres. Documentación apropiada será requerida y aprobada por USDA y Especialista de Salud.

ASSESSMENT22. Date Ht/Wt measured ____________________ Completed by:__________________________ Ht_____ Wt_____23. If 2 years old or younger: Length-for-Age Percentile ________ AND Weight for Length Percentile ________24. If more than 2 years old,: BMI for Age Percentile________

Under weight (≤ 5th percentile) Healthy weight (> 5th to < 85th percentile) Overweight (≥ 85th to < 95th percentile) Obese (≥ 95th percentile) N/A (< 2 years or pregnant)

25. Any Medical or dental diagnosis or concerns/ Diet needs/ Anemia etc.? (from Well Child Exam, Dental Exam, WIC, health/nutrition information.) Yes No Describe:__________________________________________________

26. Parent discussion on BMI or Length-for-Age and Weight-for-Age growth charts: No concern Concern, requests referral made to: __________________________________________________ Concern, but declines referral because _____________________________________________________________ WIC for further guidance from Dietician Primary provider for further guidance Other Community resource ___________________________________

27. Name of Parent Education Hand-outs discussed and given to parent: _____________________________________________________________________________________________________________________________________

Parent signature: ________________________________________________ Date: _________________________Family Advocate Signature: ___________________________________________ Date: _____________________

Health/Dental/ Nutrition #22 Original to file 01/25/18