Infant Information Sheet (under 1 year)

Infant Information Sheet

For Children under 1 Year of Age
Each Child's Infant Information Sheet must be updated every two months by the parents/guardians.
Full name of child*

First NameMiddle NameLast Name
Date of birth*

MonthDayYear
Date
Does this child take a bottle?

YesNo
Should the bottle be warmed?

YesNo
Does the child hold their bottle?

YesNo
Can the child feed themselves?

YesNo
Does the child eat:

Strained FoodsBaby FoodsTable FoodsFormulaWhole MilkBreast MilkOther
What type of formula is used?
Amount of Formula given?
Future Date to update formula amount?
Note: Parent must bring bottle containing premixed formula with child's first/last name and date located on all bottle daily.
Does the child take a pacifier?

YesNo
if applicable: Food Likes?
if applicable: Food DisLikes?
Any known allergies (include premix formula allergies:
Child's Breakfast Time

Hour Minutes

AM/PM Option
Child's Lunch Time

Hour Minutes

AM/PM Option
Child's Dinner Time

Hour Minutes

AM/PM Option
Child's Morning Nap Time

Hour Minutes

AM/PM Option
Child's Afternoon Nap Time

Hour Minutes

AM/PM Option
Additional Instructions: Type and Approximate amount of food:
Instructions for introducing Child to solid foods:
Updated instructions for adding new foods or other dietary changes:
Guardian Name

First NameLast Name
Guardian Signature

Clear
Date

MonthDayYear
Should be Empty: