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Infant Feeding plan

INSTRUCTIONS:

Prior to admission, a feeding plan shall be established and written for each infant (age six (6) weeks to twelve (12) months) in consultation with the parents and based on the written recommendation of the child's medical provider. Feeding plans must be continually updated by the child’s medical provider or parent. [470 IAC 3-4.7 (b)]

The following feeding plan has been recommended for this child.

Name of child(Required)

Date of birth (month, day, year)(Required)

Age in Months

Time to Feed

Formula / Food Item and Amount

Special Instructions

Signature of Parent or Medical Provider

Date of Parent or Medical Provider

Age in Months

Time to Feed

Formula / Food Item and Amount

Special Instructions

Signature of Parent or Medical Provider

Date of Parent or Medical Provider

Age in Months

Time to Feed

Formula / Food Item and Amount

Special Instructions

Signature of Parent or Medical Provider

Date of Parent or Medical Provider

Age in Months

Time to Feed

Formula / Food Item and Amount

Special Instructions

Signature of Parent or Medical Provider

Date of Parent or Medical Provider

Age in Months

Time to Feed

Formula / Food Item and Amount

Special Instructions

Signature of Parent or Medical Provider

Date of Parent or Medical Provider

Signature of MD, DO, NP

Date signed (month, day, year)

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