Screening for Child age Newborn - 11 Months - Pediatrics Southwest

Age / Months

Child's Name

Date of Birth

Today's Date

BREAST MILK

Feeding Method

Breast

Bottle

Both

Breastfeeding's per 24 hours

2-3

4-5

6-7

8-9

10-11

Other

Feeding frequency - Every

2 hours

3 hours

4 hours

5 hours

6 hours

7 hours

8 hours

On Demand

Other

If other, please specify

Minutes per breast

How many ounces of breast milk per bottle

> 8

FORMULA

How many ounces per bottle?

Feeding Frequency - Every

2 hours

3 hours

4 hours

5 hours

6 hours

8 hours

On Demand

Other

If other, please specify

Formula Brand

JUICE

How many ounces of juice per day

None

> 25

SOLID FOODS

WELL INFANTS

Wet Diapers per day

1 - 2

3 - 4

5 - 6

7 - 8

Stools per day

1 - 2

3 - 4

5 - 6

7 - 8

Sleeping Concerns?

Yes No

Car Seat

Rear Facing

Forward Facing

Child Care

Home

Relative

Babysitter

Day Care

When was your child's last influenza Vaccine? (For 6 months and Up)

2 Months Questionnaire

COMMUNICATIONS

1. Does your baby sometimes make throaty or gurgling sounds?

Yes Sometimes Not yet

2. Does your baby make cooing sounds such as "ooo", "gah" and "aah?"

Yes Sometimes Not yet

3. When you speak to your baby, does she make sounds back to you?

Yes Sometimes Not yet

4. Does your baby smile when you talk to him?

Yes Sometimes Not yet

5. Does your baby chuckle softly?

Yes Sometimes Not yet

6. After you have been out of sight, does your baby smile or get excited when she sees you?

Yes Sometimes Not yet

GROSS MOTOR

1. While your baby is on his back, does he wave his arms and legs, wiggle and squirm?

Yes Sometimes Not yet

2. When your baby is on his tummy, does he hold his hoead up longer than a few seconds?

Yes Sometimes Not yet

3. When our baby is on his tummy, does he hold his head up longer than a few seconds?

Yes Sometimes Not yet

4. When your baby is on her back, does she kick her legs?

Yes Sometimes Not yet

5. While your baby is on his back, does he move his head from side to side?

Yes Sometimes Not yet

6. After holding her head up while on her tummy, does your baby lay her head back down on the floor, rather than let it drop or fall forward?

Yes Sometimes Not yet

FINE MOTOR

1. Is your baby's hand usualy tightly closed when he is awake? (if your baby used to do this but no longer does, mark "yes")

Yes Sometimes Not yet

2. Does your baby grasp your finger if you touch the palm of her hand?

Yes Sometimes Not yet

3. When you put a toy in his hand, does your baby hold it in his hand briefly?

Yes Sometimes Not yet

4. Does your baby touch her face with her hands?

Yes Sometimes Not yet

5 . Does your baby hold his hands open or partly open when he is awake (rather than in fists, as they where when he was a newborn)?

Yes Sometimes Not yet

6. Does your baby grab or scratch at her clothes?

Yes Sometimes Not yet

Total

PERSONAL - SOCIAL

1. Does your baby sometimes try to suck, even when she's not feeding?

Yes Sometimes Not yet

2. Does your baby cry when he is hungry, wet, tired or wants to be held?

Yes Sometimes Not yet

3. Does your baby smile at you?

Yes Sometimes Not yet

4. When you smile at your baby, does she smile back?

Yes Sometimes Not yet

5. Does your baby watch his hands?

Yes Sometimes Not yet

6. When your baby sees the breast or bottle, does she seem to know she is about to be fed?

Yes Sometimes Not yet

Total

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