Baby's Name:                                                                                     DOB:                                      

 

Is your baby:   breastfed        bottlefed        How often?:                                                   

 

Number of bottles I will be giving the baby each day? (estimate):                                              

 

How many ounces?                                                    does he/she drink it    warm   cold

 

How to you heat the bottle?     stove     microwave               crockpot     other:                                     

 

Name of formula:                                                                                                                  

 

Will you be bringing the bottles ready made, or will I need to make them?                     

 

Any special feeding instructions?:                                                                                        

 

Does your baby need to stop feeding to burp, be changed, etc.?                                             

 

Is the baby on a schedule?:  Yes     No

 

Does baby drink juice, eat cereal or any other solid food? (Please specify): _____________

 

                                                                                                                                               

 

Do you allow the baby to have a binkie (pacifier)?            Yes      No

 

If so, when?:   just at bedtime           just when fussy                        anytime

 

Has your baby been exposed to other children often?       Yes      No

 

Please specify:                                                                                                                                                                                                           

Are any medications given regularly?                                                                                  

 

Have you made any arrangements for baby's care when I am unable?   Yes      No

 

Please specify:                                                                                                                         

What time does your baby awaken?                                                                                              

What time does your baby go to sleep at night?                                                               

Does he/she sleep through the night?                                                                                 

 

Does your baby sleep in a bed or crib                                                                                 

 

Any security toy or blanket for nap time?                                                                            

 

Does your child have any security objects such as a blankie, binkie, bottle, toy etc. that helps him/her feel better when upset? Yes      No

 

If so, what is it?                                                                                                                      

 

Are there any siblings? Please name them and specify ages and gender.

Name _____________________   age __________________ gender _______________

Name ______________________ age __________________ gender _______________

How is your child most easily settled when upset or afraid?                                                           

 

Does he/she enjoy being rocked or read/sung to?  Yes      No

 

 

 

____________________________________________                             _____/_____/_____

Parent/Guardian                                                                                Date

 

 

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