HTML Preview Blank Infant Feeding Schedule page number 1.
Revised 9/12
DEPARTMENT OF
PUBLIC HEALTH AND HUMAN SERVICES
STATE OF MONTANA
INFANT FEEDING SCHEDULE
Infant/Child’s Name: ________________________ Date of Birth: _____________
Parent’s Name: _____________________________
An individual form must be completed for all infants, ages 0 to 18 months.
Note the type of breast milk, infant formula, milk, and other foods that the infant normally uses and the average
daily amount they consume. This needs to be updated any time food is added to an infant’s diet.
Type Average Daily Amount
Breast Milk:
Infant Formula:
Milk:
Other Foods:
List the approximate times that the infant eats, what the infant normally eats at each designated time, and the
approximate amount (i.e. ounces):
Time: Breast Milk, Infant Formula, Milk, and Other Foods
List any special considerations, (i.e. food allergies):
Parent Signature Date Provider Signature Date