Visit with Parent Documentation Form

Date     Baby’s name                       Who was present                                          Age of baby           G ___P___      Family had seen HUG DVD?  Y/N

 

*On a scale of 1-5 (1 “is not very well and 5 is “great) how would you describe your ability to address this issue

Zones

Did you explain Zones to parents?

Which Zones did baby exhibit?

Did baby move suddenly between Zones?

What help did the baby need to get from one Zone to another?

 

 

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Comments:

SOS

Did you explain SOSs to parents?

 

What Body SOSs did you see?

What Behavioral SOSs did you see?

How did you respond to the SOS?

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Comments:

 

 

 

 

 

Crying

Did baby show any self calming?

Did you point out self calming to parent?

Did you demonstrate stepwise calming?

Did you explain normal change in crying patterns of babies?

 

 

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Comments:

 

 

 

 

Feeding

Did baby need help getting to the Ready Zone to eat?

 

 

Did baby show any SOSs during feeding?

 

What actions did you take in response to SOSs?

Was there some confusion about trying to feed baby while in the Resting Zone?

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Comments:

 

 

 

 

 

Sleeping

Did you explain two types of sleep?

What signs of active sleep did you observe?

Did you help parents consider how to help child “sleep through” active sleep?

 

 

Did you suggest putting baby down in active sleep?

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Comments:

 

 

 

 

 

 

 

Playing

Did you try swaddling or sucking to enhance Ready Zone for

play?

 

 

Did you get baby to orient to a ball, rattle or face?

Did you get baby to turn to parent’s voice?

Were you and/or parents surprised by baby’s abilities?

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Comments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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