Heavy Metal Baby Food Questionnaire

Please answer all questions to the best of your ability. If you have more than one child, please complete a separate questionnaire for each child.

"*" indicates required fields

Client/Legal Guardian's Information

Your Name*

First Last

Phone*

Email*

Your relationship to child:*

Person most familiar with Child's health history:*

Child's Name*

First Middle Last

Child's D.O.B*

MM slash DD slash YYYY

Child's sex assigned at birth*

Male

Female

Additional Information

Do you have paper photographs of Child from birth to present?

Yes

Do you have photographs or videos of Child from birth to present stored on any physical storage device (such as a smartphone, digital camera, DVD, computer, or external hard drive)?

Yes

If you have photographs or videos of Child from birth to present stored on any digital, electronic, web-based, or cloud-based accounts- have these accounts been “backed-up” to preserve such photos and videos?

Yes

Reasons for using baby food products?*

Do you have any baby food products left over in your possession?*

Yes

First time (approximate) the Child consumed one or more of the below Baby Foods( you may estimate to the best of your memory to the first day of any month and year. For example: if all you can remember is September of 2015, you may enter as “09/01/2015”; if all you can remember is January of 2009, you may enter as “01/01/2009”) :*

MM slash DD slash YYYY

Last time (approximate) the Child consumed one or more of the below Baby Foods( you may estimate to the best of your memory to the first day of any month and year. For example: if all you can remember is September of 2015, you may enter as “09/01/2015”; if all you can remember is January of 2009, you may enter as “01/01/2009”) :*

MM slash DD slash YYYY

Baby Food Products

Plum Organics

Did the child ever consume any Plum Organics products?*

Yes

Below please identify any Plum Organics (Baby Food/Mighty/Mashups/Jammy Sammy, etc.) products, or similar products, you believe Child ever consumed:

Please note that the below products and pictures are provided as examples . Packaging and flavor selections may have changed throughout the years and you may have purchased Plum products not identified below. If you believe Child ever consumed any of these products, or other similar products from Plum, please identify these products below by clicking on the selections that apply.

Organic Pouches (JustPeaches, Mighty Protein &Fiber, etc.)

Did the child EVER consume any Plum Organics food pouch products?*

Yes

Little Teethers Wafers(Banana with Pumpkin,Blueberry, etc.)

Did the child EVER consume any Plum Organics Little Teethers Wafers?*

Yes

Super Puffs (Apple withSpinach, Strawberry andBeet, etc.)

Did the child EVER consume any Plum Organics Super Puffs Snacks?*

Yes

Food Bars (Jammy Sammy,Mighty Snack Bars, etc.)

Did the child EVER consume any Plum Organics Food Bars products?*

Yes

Applesauce Mashups (withBlueberry & Carrot,Strawberry & Beet, etc.)

Did the child EVER consume any Plum Organics applesauce products?*

Yes

Teensy Soft Fruit Snacks(Peach, Berry, etc.)

Did the child EVER consume any Plum Organics Teensy soft fruit snacks?*

Yes

Did the child consume other products not listed above from Plum Organics?*

Yes

Please list other Plum Organics products the Child consumed that are not listed above.

HappyFamily (HappyBaby) Brand of Products

Did the child ever consume any HappyFamily (HappyBABY, HappyTOT, HappyKID) products?*

Yes

Below please identify any HappyFAMILY (HappyBABY, HappyTOT, HappyKID, etc.), products, or similar products, you believe Child ever consumed:

Please note that the below products and pictures are provided as examples . Packaging and flavor selections may have changed throughout the years and you may have purchased HappyFAMILY (HappyBABY, HappyTOT, HappyKIT) products not identified below. If you believe Child ever consumed any of these products, or other similar products from HappyFAMILY (HappyBABY, HappyTOT, HappyKID , etc. ), please identify these products below by clicking on the selections that apply.

Baby Formula (HappyBABYStage 1, Stage 1 SensitiveFormula, etc.)

Did the child EVER consume HappyBABY Formula?*

Yes

Baby Food Jars (HappyBABYApples & Spinach, Carrots,etc.)

Did the child EVER consume HappyBABY Food Jars?*

Yes

Snackers, teethers,waffle/muffin mix, greekyogis, creamies, etc.(HappyBABY)

Did the child EVER consume HappyBABY snackers, teethers,waffle/muffin mix, greek yogis, creamies, etc.?*

Yes

Food Pouches (Super Foods,Fiber & Protein,HappyBABY, HappyTOT,HappyKID)

Did the child EVER consumeHappyBABY/HappyTOT/HappyKID Food Pouches?*

Yes

Food Bars(HappyKID/HappyTOT)

Did the child EVER consume HappyKID/HappyTOT food bars,Etc.?*

Yes

Superfood Puffs(HappyBABY)

Did the child EVER consume HappyBABY Superfood Puffs?*

Yes

Oatmeal/Mac andCheese Bowls(HappyTOT)

Did the child EVER consume HappyTOTOatmeal bowls, Etc.?*

Yes

Oatmeal BabyCereal(HappyBABY)

Did the child EVER consume OatmealBaby Cereal?*

Yes

ABC Multi-grain Cookies

Did the child EVER consume ABC Multi-grain Cookies?*

Yes

Did the child consume other products not listed above from HappyFamily (HappyBABY/HappyTOT/HappyKID)?*

Yes

Please list other HappyFamily (HappyBABY/HappyTOT/HappyKID) products the Child consumed that are not listed above.

Beech-Nut Brand of Products

Did the child ever consume any Beech-Nut products?*

Yes

Below please identify any Beech-Nut products, or similar products, you believe Child ever consumed:

Please note that the below products and pictures are provided as examples . Packaging and flavor selections may have changed throughout the years and you may have purchased Beech-Nut products not identified below. If you believe Child ever consumed any of these products, or other similar products from Beech-Nut , please identify these products below by clicking on the selections that apply.

Naturals food jars (Classics/Naturals/Organics)

Did the child EVER consume any Beech-Nut food jar products?*

Yes

Naturals food pouches (fruities, veggies, etc.)

Did the child EVER consume any Beech-Nut food pouch products?*

Yes

Oatmeal or Rice Baby Cereals

Did the child EVER consume any Beech-Nut Oatmeal or Rice Baby Cereals?*

Yes

Naturals Oatmeal or Fruit/Veggie bars

Did the child EVER consume any Beech-Nut Oatmeal or Fruit/Veggie bars?*

Yes

Naturals fruit & veggie/yogurt melties

Did the child EVER consume any Beech-Nut fruit & veggie/yogurt melties?*

Yes

Naturals baked cheese/veggie chips

Did the child EVER consume any Beech-Nut baked cheese/veggie chips?*

Yes

Did the child consume other products not listed above from Beech-Nut?*

Yes

Please list other Beech-Nut products the Child consumed that are not listed above.

Sprout Organic Baby Food Products

Did the child ever consume any Sprouts FOOD products?*

Yes

Below please identify any Sprout Organic Foods, or similar products, you believe Child ever consumed:

Please note that the below products and pictures are provided as examples . Packaging and flavor selections may have changed throughout the years and you may have purchased Sprout Organic Foods products not identified below. If you believe Child ever consumed any of these products, or other similar products from Sprout Organic Foods , please identify these products below by clicking on the selections that apply.

Any food pouch products (Protein, Fruit&Veggie Blends,Smoothies, etc.)

Did the child EVER consume any Sprout Organic Foods food pouches?*

Yes

Any Toddler Meals (Baby Burrito Bowls, Butternut Mac &Cheese, etc.)

Did the child EVER consume any Sprout Organic Foods Toddler Meals?*

Yes

Plant Power Puffs (Apple Kale Power Puffs, Carrot PeachMango Plant, etc.)

Did the child EVER consume any Sprout Organic Foods Power Puffs products?*

Yes

Any Toddler Snacks (Crinkles, Curlz, Crispy Chewz, Wafflez,etc.)

Did the child EVER consume any Sprout Organic Foods Toddler Snacks?*

Yes

Did the child consume other products not listed above from Sprout Organic Foods?*

Yes

Please list other Sprout Organic Foods products the Child consumed that are not listed above.

Parent's Choice (Walmart) Baby Food Products

Below please identify any Parent's Choice, or similar products, you believe Child ever consumed:

Please note that the below products and pictures are provided as examples . Packaging and flavor selections may have changed throughout the years and you may have purchased Parent's Choice products not identified below. If you believe Child ever consumed any of these products, or other similar products from Parent's Choice , please identify these products below by clicking on the selections that apply.

Baby Food Jars and Plastic Containers (Banana, Pear, etc.)

Did the child EVER consume any Parent’s Choice food jars or plastic packaged products?*

Yes

Food Pouches (Organic Pear, Mango, Brow Rice, Macaroniand Cheese, etc.)

Did the child EVER consume any Parent’s Choice food pouch products?*

Yes

Puffed Grain Snacks (Banana, Blueberry, Strawberry, etc.)

Did the child EVER consume any Parent’s Choice puffed grain snacks?*

Yes

Rice Rusks (Apple, Banana, Strawberry, etc.)

Did the child EVER consume any Parent’s Choice rice rusk products?*

Yes

Soy-Based Infant Baby Formula (Tender, CompleteComfort, etc.)

Did the child EVER consume any Parent’s Choice infant formula products?*

Yes

Yogurt Bites (Banana, Cherry Vanilla, Peach, etc.)

Did the child EVER consume any Parent’s Choice yogurt bites products?*

Yes

Did the child consume other products not listed above from Parent's Choice?*

Yes

Please list other Parent’s Choice products the Child consumed that are not listed above.

Earth's Best Organic Food Products

Did the child ever consume any Earth's Best FOOD products?*

Yes

Below please identify any Earth's Best, or similar products, you believe Child ever consumed:

Please note that the below products and pictures are provided as examples . Packaging and flavor selections may have changed throughout the years and you may have purchased Earth's Best products not identified below. If you believe Child ever consumed any of these products, or other similar products from Earth's Best , please identify these products below by clicking on the selections that apply.

Food Jars (Carrots, Turkey Broth, Sweet Potato & Chicken,etc.)

Did the child EVER consume any Earth's Best food jar products?*

Yes

Food Pouches (Protein Puree, Banana Puree, ChickenCasserole, etc.)

Did the child EVER consume any Earth's Best food pouch products?*

Yes

Soy-Based Infant Baby Formula (Organic Dairy,Plat Based, etc.)

Did the child EVER consume any Earth's Best infant baby formula products?*

Yes

Infant Cereals (Oatmeal, Rice, Milti-Grain, etc.)

Did the child EVER consume any Earth's Best cereal products?*

Yes

Grain-Based Snacks (Bars, Graham Crackers, PeanutButter Puffs, etc.)

Did the child EVER consume any Earth's Best grain-based snacks?*

Yes

Frozen Entrees and Meals (Baked Popcorn ChickenNuggets, Chicken Fries, Veggie Medley Nuggets, MeatlessChik'n Nuggets, Broccoli & Cheese Nuggets, etc.)

Did the child EVER consume any Earth's Best frozen entrees?*

Yes

Fruit Yogurt Smoothies (Strawberry Banana, Pear Mango,etc.)

Did the child EVER consume any Earth's Best fruit yogurt products?*

Yes

Electrolyte Solution (Apple Orange, Grape, etc.)

Did the child EVER consume any Earth's Best electrolyte products?*

Yes

Did the child consume other products not listed above from Earth's Best?*

Yes

Please list other Earth’s Best products the Child consumed that are not listed above.

Gerber Food Products

Did the child ever consume any Gerber FOOD products?*

Yes

Below please identify any Gerber, or similar products, you believe Child ever consumed:

Please note that the below products and pictures are provided as examples . Packaging and flavor selections may have changed throughout the years and you may have purchased Gerber products not identified below. If you believe Child ever consumed any of these products, or other similar products from Gerber , please identify these products below by clicking on the selections that apply.

Baby Formula (Good Start, AN Pro, Soy based, etc.)

Did the child EVER consume any Gerber Baby Formula products?*

Yes

Food Jars and Tubs (Apple Strawberry Banana, Pea,Garden Veggies & Rice, etc.))

Did the child EVER consume any Gerber food jars or tub products?*

Yes

Food pouches (Organic Veggie Power, Natural, Fruit &Yogurt, etc)

Did the child EVER consume any Gerber food pouch products?*

Yes

Single Grain and Multi-Grain Cereals (Rice, Oatmeal &Barley Apple Cinnamon, Organic Oatmeal, etc.)

Did the child EVER consume any Gerber cereal products?*

Yes

Puffs Snacks (Sweet Potato, Strawberry Apple, Banana,Puffs to Go, etc.)

Did the child EVER consume any Gerber Puff Snacks?*

Yes

Biscuits and Cookies (Arrowroot Biscuits, Organic HoneyBiscuits, etc.)

Did the child EVER consume any Gerber biscuits or cookie products?*

Yes

Grain Bars (Strawberry Banana, Organic Banana MangoPineapple, etc.)

Did the child EVER consume any Gerber Grain Bars?*

Yes

Did the child consume other products not listed above from Gerber Foods?*

Yes

Please list other Gerber products the Child consumed that are not listed above.

Information on How Baby Food was Obtained

How did you purchase the Baby Food listed above that the Child consumed? (select all that apply)*

Online

In-store

Delivery service

If you used a delivery service to purchase the Baby Food listed above that the Child consumed, what was it? (Examples: Instacart, Shipt, Postmates, DoorDash, Grubhub, GoPuff, Uber)

Where did you purchase the Baby Food listed above that the Child consumed? Please name all stores. (Examples: Walmart, Target, CVS, Walgreens, Sam’s Club, Costco, ABC Supermarket, Instacart, Shipt, Amazon, etc.)*

Comments

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Heavy Metal Baby Food Questionnaire