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fields (labelled below in red) have been filled in
Please note that all fields followed by an asterisk must be filled in. First Name*
Country United States Canada ---------------- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribadi North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Federated States of Micronesia Moldova Monaco Mongolia Montserrat Morocco Montenegro Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda S. Georgia and S. Sandwich Isls. Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam US Virgin Islands Wallis and Futuna Islands Western Sahara Yemen Yugoslavia (former) Zaire Zambia Zimbabwe Home Phone*
Baby's Date of Birth*
Was Baby Full Term
Any Pregnancy Complications (if yes, explain)*
Any Delivery Complications (if yes, explain)
Any Experiences With Jaundice
Feedings In Past 7 Days (nights feedings included)
Other Dairy (yogurt, cheese, ice cream, pudding, ect)
Soy Foods (tofu, frozen soy desserts, etc)
Fruit / Veggie Juice (100% only)
Other Starches (teething biscuits, crackers, breads, pasta, rice)
Fish / Shellfish
Nut Products (peanut, almond, etc)
Eggs Other Foods Not Listed
Check All Cereals Given in Last 7 days
Below is a list of vitamins, mineral drops or pills. Please check all that were give 3 times a day in the last 2 weeks. Please check all items if in a combination suppliment)
During the past 2 weeks, how often was your baby put to bed with a bottle of formula, breast milk, juice, juice drink, or any other kind of milk?
Was Baby Formula Fed In Past 7 Days?
How often does your baby drink all of his or her bottle of formula?
In the past 7 days, about how many ounces of formula did your baby drink at each feeding?
How often is your baby encouraged to finish a bottle if they stop drinking before bottle is empty?
What type of formula was your baby fed in past 7 days? Please check all that apply.
Which of the following describes the iron content of the formula you usually use?
Was Baby Breast Milk Fed In Past 7 Days?
Does baby feed from both breasts during each feeding?
Does baby usually let go of the breast themselves?
About how long does an average breastfeeding last?
Which of the following problems did your baby have during the past 2 weeks? Please check all that apply.
Did your baby receive any of the following medicines in the past 2 weeks?
How many stools (dirty diapers) does your baby usually have in a 24-hour period? If less than one a day, how many days usually pass between stools? ____ NUMBER OF STOOLS IN 24 HOURS OR ONE STOOL EVERY ____________ DAYS.
How would you describe your baby’s stool in the past 7 days? Please check all that apply.
Please enter the word that you see below.