WIC Nutrition Assessment for Infants

1

Infant's Name

First Name

Last Name

2

Infant's Date of Birth

Date

3

Has the doctor ever told you that your baby has any medical conditions or illnesses?

YESNO

4

Please indicate the conditions or illness

5

When is your baby's next doctor appointment?

Date

6

What are you feeding your baby?Select all that apply

Breastmilk

Formula

Other liquids or beverages (not infant formula)

Baby food or family/table food

7

What type of formula?

8

What type of liquids, beverages, baby food or table food?

10

Do you dip your baby’s pacifier in sugar, syrup or honey, or add sugar, syrup or honey to breastmilk or formula?

YESNO

11

Does your baby eat honey or any foods made with honey such as honey graham crackers, muffins, etc.?

YESNO

12

Which of the following foods does your baby eat?Select all that apply.

Fresh squeezed fruit or vegetable juices

Unpasteurized (farm fresh) dairy products

Soft cheeses such as Feta, Brie, Camembert, Blue-veined cheese, Queso-Blanco or Queso-Fresco

Raw or undercooked meats, fish, chicken, turkey or eggs

Raw sprouts (alfalfa, clover, bean, radish)

Uncooked luncheon meats, deli meats, hot dogs

None of the Above

13

Have you noticed any oral or dental problems with (in) your baby's mouth?

YESNO

14

Please indicate the oral/dental problems you've noticed.