Infants Information Sheet

Child’s Name ______________________________ Date of Birth __________________

Mother (Guardian) _______________________________________________________

Father (Guardian) _______________________________________________________

Marital Status of Parents:

Married ________ Divorced ________ Separated _______ Single Parent _________

Custody/Visiting Arrangements _____________________________________________

Brothers and Sisters of Child:

Name __________________________________ Birth Date ________________

Name __________________________________ Birth Date ________________

Name __________________________________ Birth Date ________________

Other Members of Household:

Name __________________________________ Age _______

Name __________________________________ Age _______

Birth Weight _________________________ Birth Height _____________________

Was there anything unusual about the delivery? Please explain. ___________________________________________________________

Has your baby ever been separated from you before? Please explain. ___________________________________________________________

How would you best describe your baby’s behavior? (Circle the words that are applicable.)

______Sleepy ______Light Sleeper ______Heavy Sleeper ______Wakeful

How many hours a day and night does your baby sleep? ________________________

What time does your baby nap during the day? ________________________________

Does your baby use a pacifier? _________ When? _____________________________

Does your baby have a special blanket? ______________________________________

Was your baby breast-fed? _______________________________________________

When was your baby weaned to a bottle? ____________________________________

When do you give a bottle to your baby? _____________________________________

How much does your baby usually drink at a feeding? ___________________________

What kind of formula do you use? ___________________________________________

Is solid food given? Yes ____ No ____ Please explain. ___________________________________________________________