DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES
STATE OF MONTANA
INFANT FEEDING SCHEDULE
Child's Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Child's Birthdate
*
-
Month
-
Day
Year
Date
FORMULA
Is your child fed formula?
Yes
No
Will formula be prepared (mixed) at home?
Yes
No
Will formula be prepared by the caregiver?
Yes
No
If the caregiver will be preparing the formula, please indicate any special instructions:
BREAST FEEDING/BREASTMILK
Is your child breast-fed?
Yes
No
I will nurse my child at the center at these times
Yes
No
If " YES" please indicate the time
I will provide breast milk
Yes
No
If breast milk is unavailable for a feeding, the center should
FEEDINGS
Does your child take a bottle? (Note: Bottles are required to be labeled with child's name and the current date.)
Yes
No
Yes
No
Is the bottle warmed?
Does your child hold their bottle?
Can the child feed himself or herself?
Are there any special instructions for bottle-feeding your child?
If "YES" please explain:
Is your child using a sippy cup? (Note: Sippy cups must be labeled with the child's name)
Yes
No
Does your child have any problems with feeding, such as choking or spitting up?
Yes
No
If " YES" please explain
Are there any special instructions concerning feeding your child?
Yes
No
If " YES" please explain
FOODS and FEEDING SCHEDULE
LIQUIDS (formula, breastmilk)
N/A
Introducing
Familiar
Breast Feeding
By Bottle
By Breast
Bottle Feeding
By Caregiver
With help
Independently
Cup Feeding
with help
independently
Amounts
Semisolid Foods ( infant cereal, strained fruits, and / or vegetables)
N/A
Introducing
Familiar
Spoon Feeding
By caregiver
With Help
Independently
Kinds of food
Amounts
Modified Table Foods
N/A
Introducing
Familiar
Spoon Feeding
By caregiver
With help
Independently
Kinds of food
Amout
Finger Foods
N/A
Introducing
Familiar
Spoon Feeding
By caregiver
with help
Independently
Kinds of Food
Amounts
Other
Does your child take a pacifier? (Note: Pacifiers with straps or other types of attachment devices are not permitted. Pacifiers must be removed when child is crawling or walking.)
Yes
No
Additional Information:
I will promptly provide any updates to my child's feeding plan as needed.
Parent Signature
*
Date
*
-
Month
-
Day
Year
Date
Breast milk shall be gently mixed but not be shaken. Refrigerated breast milk shall be used within 24 hours. Formula or breast milk that is served but not completely consumed or refrigerated, shall be discarded. No milk, formula, or breast milk shall be warmed in a microwave oven.
Submit
Should be Empty: