Baby's Information Sheet

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