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Nutrition Interventions for Children with Special Health Care Needs

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Appendix A<br />

Baby <strong>for</strong>mula What kind of <strong>for</strong>mula? (<strong>with</strong>/<strong>with</strong>out iron?)<br />

How do you mix the <strong>for</strong>mula?<br />

Are Any of These a Problem <strong>for</strong> Your Child? If yes, please check.<br />

vomiting gagging and choking eating too slowly<br />

diarrhea chewing refusing to eat<br />

constipation cup drinking spitting out food<br />

sucking on nipple finger feeding getting upset at meals<br />

holding up head not eating solid foods after 1 yr. poor appetite/picky eater<br />

sitting up alone bad teeth/sore mouth not self-feeding<br />

swallowing food allergies<br />

Other concerns:<br />

DX<br />

PHN please complete<br />

Height Weight %tiles: Ht/age Wt/age<br />

Wt/Ht<br />

Birthweight (< 2 years)<br />

dl<br />

OFC Hematocrit % Hemoglobin Gm/<br />

Comments:<br />

Medical <strong>Care</strong> Provider Phone<br />

PHN Clinic Phone<br />

Name<br />

DOB Patient I.D.#<br />

Seattle-King County Department of Public <strong>Health</strong><br />

CS #13.19.87 Rev. 5/90<br />

NUTRQUES.PM3<br />

278 <strong>Nutrition</strong> <strong>Interventions</strong> <strong>for</strong> <strong>Children</strong> With <strong>Special</strong> <strong>Health</strong> <strong>Care</strong> <strong>Needs</strong>

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