Alaska Program Infant Application
ADVERTISEMENT
1
2Infant Application
Today’s Date _________________
_____________________________________________
_____________
or
_______lbs _______oz ___ _____in”
Boy
Girl
Last Name
First Name
Middle Initial
Birth Date
Weight
Length
Your Name: ________________________________ Relationship to Child: _____________________________________
If Infant is on Medicaid, please provide the Medicaid number or Infant’s SSN:_________________________________
Is this baby Hispanic or Latino?
No
Yes
American Indian/Alaska Native
Asian
White
Select at least one of the following:
Black/African American
Native Hawaiian/Pacific Islander
My baby’s birth weight was less than 5 lbs. 9 oz
No
Yes 141
My baby was born at 37 weeks or less
No
Yes 142 How many weeks did your pregnancy last?_____________
My baby weighted more than 9 pounds at birth
No
Yes 153
My baby’s immunizations are up to date
No
Yes
WIC helps families with healthy food and nutrition choices.
What concerns, if any, do you have about what, how or how much your baby eats?
342, 411.04
____________________________________________________________________________________
____________________________________________________________________________________
1.
At what Birthing Facility was the Infant born?
11.
Does your family stay in a shelter, a temporary home, or in
a place not usually used for sleeping?
_______________________________________________
2.
Please, tell us if your baby sees a doctor, dietitian or health
No
Yes 801
care provider for medical reasons, ex: hypertension, pre-
12.
Do you have a refrigerator, a stove that works and storage
hypertension, diabetes, fetal alcohol syndrome, small for
free from pests and harmful chemicals?
gestational age, gastrointestinal disorders or anemia. 151,
No
Yes 801
152, 201, 341-357, 359, 360, 362, 382
13.
Did a family member have a seasonal farming job with a
Describe: ___________________________________
temporary home in the last 24 months?
____________________________________________
No
Yes 802
3.
If your baby was in the hospital in the last 3 months,
14.
please, tell us why.
359
What concerns, if any, do you have about anyone hurting
your baby? _________________________
___________________________________________
___________________________________________
_______________________________________________
_________ 901
4.
Has your baby been screened or referred for lead
15.
poisoning?
No
Yes 211
Do you have problems taking care of your baby?
No
Yes 703,
5.
Please, describe any teething problems your baby may be
902
having.
_________________________________________
16.
Has your baby been in foster care or moved to a new foster
care home within the last 6 months?
_________________________________________381
No
Yes 903
6.
Does your baby have any food intolerances or food
17.
What concerns, if any, do you have about having enough
allergies?
No
Yes 353, 354, 355
food to feed your family?
Describe: __________________________________
Comment: __________________________________
___________________________________________
__________________________________________
7.
Is your baby on a special diet?
No
Yes 411.8
18.
How are you feeding your baby?
8.
What vitamin, mineral or herbal supplement do you give
Breastmilk
Breastmilk + Formula
Formula Only
your baby? _____________________________
If not daily, how often?_______________ 411.10, 411.11
9.
List any medication your baby may be taking.
357
If breastfeeding
19.
On what date did breastfeeding begin?
___________________________________________________
_________________________________
10.
Does anyone smoke cigarettes, cigars, or pipes anywhere
inside your home?
No
Yes 904
***To Be Completed by Health Care Provider (HCP)***
Medical date______________
Current Wt _________ (103, 113, 134, 135)
Ht _________ (121)
Hgb /Hct __________(201)
Thank you!
Rev 9/ Infant Application
Name of HCP verifying applicant lives in Alaska ___________________________________ID Verified by: Visual Recognition___/Other _______WIC
Name of CPA reviewing WIC application_________________________________________ Certification Date _______________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical