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WIC Nutrition Assessment for Infants
Missouri Department of Health & Senior Services | WIC and Nutrition Services
14
Questions
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1
Infant's Name
First Name
Last Name
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2
Infant's Date of Birth
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Date
Month
Day
Year
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3
Has the doctor ever told you that your baby has any medical conditions or illnesses?
YES
NO
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4
Please indicate the conditions or illness
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5
When is your baby's next doctor appointment?
-
Date
Month
Day
Year
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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
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7
What type of formula?
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8
What type of liquids, beverages, baby food or table food?
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9
Where are all the places your baby takes a bottle or cup?
Select all that apply.
Breastfeeding only/no bottles
Bed
Stroller
Car seat
Held by someone
High chair
Holds his/her own bottle
Other
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10
Do you dip your baby’s pacifier in sugar, syrup or honey, or add sugar, syrup or honey to breastmilk or formula?
YES
NO
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11
Does your baby eat honey or any foods made with honey such as honey graham crackers, muffins, etc.?
YES
NO
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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
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13
Have you noticed any oral or dental problems with (in) your baby's mouth?
YES
NO
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14
Please indicate the oral/dental problems you've noticed.
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