Free HealthCheck Infant's Food Record, HCF 01066 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1066 (07/08)

STATE OF WISCONSIN

HEALTHCHECK INFANT'S FOOD RECORD (Birth to 12 Months of Age)

Name of Infant

Date

Directions: Write down everything your baby ate or drank in the last 24 hours (meals and snacks). Start with the first morning feeding yesterday to the first morning feeding today.
Example 3:00 AM Home 7:00 AM Home 9:00 AM Sitter TIME PLACE Breastfed Breastfed 3 ounces SMA with Iron, concentrate (made with 1 can concentrate and 1 can water) AMOUNT AND FOOD OR BEVERAGE CONSUMED

OFFICE USE ONLY

Ounces of formula

Number Breast Feed

Bread

Vegetables

Fruit

Meat

1. Is this the way your baby eats most of the time?

Yes

No

If no, why not?

2. What is fed to your baby in a bottle? Milk Jello Water Other

Breast Milk Tea

Formula

Juices

Water Cereal

3. Check any problems your baby has during feedings. Chokes and Gags Is a fussy eater

Other

4. Where does your baby's drinking water come from? Well City Water Bottled Water

Don't know Never

5. How often does your baby go to a babysitter or day care? _____ days a weeks If baby goes to sitter or day care, are meals / food provided? Yes No 6. When you are short of money for your baby's food or formula, what do you do?