Document
Infant Feeding Log (PB, EH, TT-HI)

ICR 201104-0925-002 · OMB 0925-0593 · Object 24140701.
This document may belong to an older filing. More recent activity for OMB 0925-0593:
Document Viewer [docx]

Status: Original and derived artifacts are available for this document.
Download: docx | pdf | html
Primary: docxSource: application/vnd.openxmlformats-officedocument.wordprocessingml.document
Loading document viewer…
Document Metadata

Record metadata
File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Infant Feeding Log (PB, EH, TT-HI)
Last Modified By	Writer
File Modified	2011-04-06
File Created	2026-08-24
Conversion State	complete
Extracted Text

Infant and Child Health Care Log 
(Birth to 6 years old)
			

Infant and Child Health Care Log





Inform the National Children’s Study staff when more pages are needed.

LOG FOR OUTPATIENT HEALTH CARE VISITS AND OVERNIGHT HOSPITAL STAYS
1
2
3
4
5
6
7
8
9
10
Date of visit
Health Care Provider # from Health Care Provider Log
Reason for visit
(check all that apply)
Weight
Length/ Height 
Head circumference
(0-2 yrs.)
Immunization/
Vaccination/
Shot

Tests/ Medications/ Treatments
e.g., lab tests (blood, urine. . .), medicines, vitamins, minerals, herbs, supplements, procedures
Diagnosis or Problem

Completed by Office or Self









Date Reported to NCS
March 3, 2010


0
√   Routine well visit
    • Sick visit
    • Specialist doctor visit
    • Emergency visit
    • Immunization/ vaccination/ shot 
    • Follow-up visit
    • Overnight hospital stay
How many nights? ___
    • Some other reason (explain): 
_________________________
              
__10__lb pounds
 
_4___ oz.
ounces 
OR

______kg
kilograms    

    • Not Done/Don’t Know
              
__23_ in 
Inches 

     
OR
 
_____cm 
centimeters

    • Not Done/Don’t Know

__37_ cm
centimeters     
    

OR

_____ in 
Inches

    • Not Done/Don’t Know

    • NO

√  YES, 
If ‘YES’ then go to Immunization / Vaccination / 
Shot Log
  Lab test (blood)



Well infant, good growth and development


 
√  Office
 Self










Date: 
March  4, 2011





    • Routine well visit
    • Sick visit
    • Specialist doctor  visit
    • Emergency visit
    • Immunization/vaccination/shot 
    • Follow-up visit 
    • Overnight hospital stay
How many nights? ____
    • Some other reason (explain): 
_________________________
              
_______lb  pounds 
______ oz.
ounces 
     OR

_______ kg
kilograms    

    • Not Done/Don’t Know
              
_______ in 
Inches 
     

OR
 
_______cm 
 centimeters 

    • Not Done/Don’t Know

________ cm
centimeters     
    

OR

________ in 
Inches

    • Not Done/Don’t Know

    • NO

    • YES,
If ‘YES’ then go to Immunization / Vaccination / 
Shot Log 




















 Office
 Self


      






Date: 
_________





    • Routine well visit
    • Sick visit
    • Specialist doctor  visit
    • Emergency visit
    • Immunization/vaccination/shot 
    • Follow-up visit 
    • Overnight hospital stay
How many nights? ____
    • Some other reason (explain): 
_________________________
              
_______lb  pounds 
______ oz.
ounces 
     OR

_______ kg
kilograms    

    • Not Done/Don’t Know
              
_______ in 
Inches 
     

OR
 
_______cm 
 centimeters 

    • Not Done/Don’t Know

________ cm
centimeters     
    

OR

________ in 
Inches

    • Not Done/Don’t Know

    • NO

    • YES,
If ‘YES’ then go to Immunization / Vaccination / 
Shot Log 




















 Office
 Self


      






Date: 
_________
LOG FOR OUTPATIENT HEALTH CARE VISITS AND OVERNIGHT HOSPITAL STAYS
1
2
3
4
5
6
7
8
9
10
Date of visit
Health Care Provider # from Health Care Provider Log
Reason for visit
(check all that apply)
Weight
Length/ Height 
Head circumference
(0-2 yrs.)
Immunization/
Vaccination/
Shot

Tests/ Medications/ Treatments
e.g., lab tests (blood, urine. . .), medicines, vitamins, minerals, herbs, supplements, procedures
Diagnosis or Problem

Completed by Office or Self









Date Reported to NCS





    • Routine well visit
    • Sick visit
    • Specialist doctor  visit
    • Emergency visit
    • Immunization/vaccination/shot 
    • Follow-up visit 
    • Overnight hospital stay
How many nights? ____
    • Some other reason (explain): 
_________________________
              
_______lb  pounds 
______ oz.
ounces 
     OR

_______ kg
kilograms    

    • Not Done/Don’t Know
              
_______ in 
Inches 
     

OR
 
_______cm 
 centimeters 

    • Not Done/Don’t Know

________ cm
centimeters     
    

OR

________ in 
Inches

    • Not Done/Don’t Know

    • NO

    • YES,
If ‘YES’ then go to Immunization / Vaccination / 
Shot Log 




















 Office
 Self









Date: 
_________





    • Routine well visit
    • Sick visit
    • Specialist doctor  visit
    • Emergency visit
    • Immunization/vaccination/shot 
    • Follow-up visit 
    • Overnight hospital stay
How many nights? ____
    • Some other reason (explain): 
_________________________
              
_______lb  pounds 
______ oz.
ounces 
     OR

_______ kg
kilograms    

    • Not Done/Don’t Know
              
_______ in 
Inches 
     

OR
 
_______cm 
 centimeters 

    • Not Done/Don’t Know

________ cm
centimeters     
    

OR

________ in 
Inches

    • Not Done/Don’t Know

    • NO

    • YES,
If ‘YES’ then go to Immunization / Vaccination / 
Shot Log 




















 Office
 Self


      






Date: 
_________





    • Routine well visit
    • Sick visit
    • Specialist doctor  visit
    • Emergency visit
    • Immunization/vaccination/shot 
    • Follow-up visit 
    • Overnight hospital stay
How many nights? ____
    • Some other reason (explain): 
_________________________
              
_______lb  pounds 
______ oz.
ounces 
     OR

_______ kg
kilograms    

    • Not Done/Don’t Know
              
_______ in 
Inches 
     

OR
 
_______cm 
 centimeters 

    • Not Done/Don’t Know

________ cm
centimeters     
    

OR

________ in 
Inches

    • Not Done/Don’t Know

    • NO

    • YES,
If ‘YES’ then go to Immunization / Vaccination / 
Shot Log 




















 Office
 Self


      






Date: 
_________

LOG FOR OUTPATIENT HEALTH CARE VISITS AND OVERNIGHT HOSPITAL STAYS
1
2
3
4
5
6
7
8
9
10
Date of visit
Health Care Provider # from Health Care Provider Log
Reason for visit
(check all that apply)
Weight
Length/ Height 
Head circumference
(0-2 yrs.)
Immunization/
Vaccination/
Shot

Tests/ Medications/ Treatments
e.g., lab tests (blood, urine. . .), medicines, vitamins, minerals, herbs, supplements, procedures
Diagnosis or Problem

Completed by Office or Self









Date Reported to NCS





    • Routine well visit
    • Sick visit
    • Specialist doctor  visit
    • Emergency visit
    • Immunization/vaccination/shot 
    • Follow-up visit 
    • Overnight hospital stay
How many nights? ____
    • Some other reason (explain): 
_________________________
              
_______lb  pounds 
______ oz.
ounces 
     OR

_______ kg
kilograms    

    • Not Done/Don’t Know
              
_______ in 
Inches 
     

OR
 
_______cm 
 centimeters 

    • Not Done/Don’t Know

________ cm
centimeters     
    

OR

________ in 
Inches

    • Not Done/Don’t Know

    • NO

    • YES,
If ‘YES’ then go to Immunization / Vaccination / 
Shot Log 




















 Office
 Self









Date: 
_________





    • Routine well visit
    • Sick visit
    • Specialist doctor  visit
    • Emergency visit
    • Immunization/vaccination/shot 
    • Follow-up visit 
    • Overnight hospital stay
How many nights? ____
    • Some other reason (explain): 
_________________________
              
_______lb  pounds 
______ oz.
ounces 
     OR

_______ kg
kilograms    

    • Not Done/Don’t Know
              
_______ in 
Inches 
     

OR
 
_______cm 
 centimeters 

    • Not Done/Don’t Know

________ cm
centimeters     
    

OR

________ in 
Inches

    • Not Done/Don’t Know

    • NO

    • YES,
If ‘YES’ then go to Immunization / Vaccination / 
Shot Log 




















 Office
 Self


      






Date: 
_________





    • Routine well visit
    • Sick visit
    • Specialist doctor  visit
    • Emergency visit
    • Immunization/vaccination/shot 
    • Follow-up visit 
    • Overnight hospital stay
How many nights? ____
    • Some other reason (explain): 
_________________________
              
_______lb  pounds 
______ oz.
ounces 
     OR

_______ kg
kilograms    

    • Not Done/Don’t Know
              
_______ in 
Inches 
     

OR
 
_______cm 
 centimeters 

    • Not Done/Don’t Know

________ cm
centimeters     
    

OR

________ in 
Inches

    • Not Done/Don’t Know

    • NO

    • YES,
If ‘YES’ then go to Immunization / Vaccination / 
Shot Log 




















 Office
 Self


      






Date: 
_________

LOG FOR OUTPATIENT HEALTH CARE VISITS AND OVERNIGHT HOSPITAL STAYS
1
2
3
4
5
6
7
8
9
10
Date of visit
Health Care Provider # from Health Care Provider Log
Reason for visit
(check all that apply)
Weight
Length/ Height 
Head circumference
(0-2 yrs.)
Immunization/
Vaccination/
Shot

Tests/ Medications/ Treatments
e.g., lab tests (blood, urine. . .), medicines, vitamins, minerals, herbs, supplements, procedures
Diagnosis or Problem

Completed by Office or Self









Date Reported to NCS





    • Routine well visit
    • Sick visit
    • Specialist doctor  visit
    • Emergency visit
    • Immunization/vaccination/shot 
    • Follow-up visit 
    • Overnight hospital stay
How many nights? ____
    • Some other reason (explain): 
_________________________
              
_______lb  pounds 
______ oz.
ounces 
     OR

_______ kg
kilograms    

    • Not Done/Don’t Know
              
_______ in 
Inches 
     

OR
 
_______cm 
 centimeters 

    • Not Done/Don’t Know

________ cm
centimeters     
    

OR

________ in 
Inches

    • Not Done/Don’t Know

    • NO

    • YES,
If ‘YES’ then go to Immunization / Vaccination / 
Shot Log 




















 Office
 Self









Date: 
_________





    • Routine well visit
    • Sick visit
    • Specialist doctor  visit
    • Emergency visit
    • Immunization/vaccination/shot 
    • Follow-up visit 
    • Overnight hospital stay
How many nights? ____
    • Some other reason (explain): 
_________________________
              
_______lb  pounds 
______ oz.
ounces 
     OR

_______ kg
kilograms    

    • Not Done/Don’t Know
              
_______ in 
Inches 
     

OR
 
_______cm 
 centimeters 

    • Not Done/Don’t Know

________ cm
centimeters     
    

OR

________ in 
Inches

    • Not Done/Don’t Know

    • NO

    • YES,
If ‘YES’ then go to Immunization / Vaccination / 
Shot Log 




















 Office
 Self


      






Date: 
_________





    • Routine well visit
    • Sick visit
    • Specialist doctor  visit
    • Emergency visit
    • Immunization/vaccination/shot 
    • Follow-up visit 
    • Overnight hospital stay
How many nights? ____
    • Some other reason (explain): 
_________________________
              
_______lb  pounds 
______ oz.
ounces 
     OR

_______ kg
kilograms    

    • Not Done/Don’t Know
              
_______ in 
Inches 
     

OR
 
_______cm 
 centimeters 

    • Not Done/Don’t Know

________ cm
centimeters     
    

OR

________ in 
Inches

    • Not Done/Don’t Know

    • NO

    • YES,
If ‘YES’ then go to Immunization / Vaccination / 
Shot Log 




















 Office
 Self


      






Date: 
_________
Inform the National Children’s Study staff when more pages are needed.
Inform the National Children’s Study staff when more pages are needed.