Olympic Educational Service District 114

105 National Avenue North, Bremerton, Washington 98312

(360) 478-6887  1-800-201-1300  FAX (360) 405-5808

EARLY HEAD START 2-WEEK NEWBORN VISIT ACTION LOG

Baby’s Name: Click or tap here to enter text. Today’s Date: Click or tap to enter a date.

Name of Parent/Guardian: Click or tap here to enter text.

Individuals Present: Click or tap here to enter text.

Due Date: Click or tap to enter a date. Birth Date: Click or tap to enter a date.

Birth Weight: Click or tap here to enter text. Today’s Weight: Click or tap here to enter text.

Baby’s Medical Home: Click or tap here to enter text. Doctor’s Name: Click or tap here to enter text.

Next Scheduled Doctor’s Appointment for Baby: Click or tap to enter a date.

Baby’s General Health (how is baby doing, questions, concerns): Click or tap here to enter text.

Baby’s Sleep (sleep patterns/environment): Click or tap here to enter text.

Breastfeeding/Bottle Feeding (how is it going, questions, concerns): Click or tap here to enter text.

Diapers (does baby have a least 4 wet diapers in a 24-hour period?): Click or tap here to enter text.

Adjustment (mom, dad, additional family members): Click or tap here to enter text.

Mom’s Recovery (sleep, nutrition, overall recovery from giving birth): Click or tap here to enter text.

Next Scheduled Doctor’s Appointment for Mom: Click or tap to enter a date.

Do You Have a Public Health Nurse (PHN)? Choose an item.

If YES, Name of PHN: Click or tap here to enter text.

Next Scheduled Public Health Nurse Appointment: Click or tap to enter a date.

Additional Information and Follow-Up Needed: Click or tap here to enter text.

FAMILY ACCEPTS ☐

By selecting the “FAMILY ACCEPTS” button, you are verifying that you have spoken directly to this family regarding this 2-Week Newborn Visit Action Log and the family has agreed to this Action Log and to share information.

Family Name (first and last): Click or tap here to enter text. Staff Name (first and last): Click or tap here to enter text.

Date: Click or tap to enter a date.