Wic Medical Referral Form For Women
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1Date Mailed/
NEW YORK STATE DEPARTMENT OF HEALTH
For WIC
Date Rec’d
Given
Use:
DIVISION OF NUTRITION
Appt Date
WIC ID #
WIC MEDICAL REFERRAL FORM FOR WOMEN
Last Name (Print):_____________________________________
First Name: _______________________________________________
Street:____________________________________Apt:_______
City: _____________________________
Zip:_________________
□
□
Phone: ( ) ________ ‐ ________
Date of Birth: ______/______/______
On WIC Before: Yes
No
Maiden Name:_____________________________________________
Language(s) Spoken: __________________________________
I authorize __________________________________________________(Health Care Provider) to release the information below to the WIC Program, and I authorize
the WIC Program to release information about me to this health care provider for the purposes of coordinating my health care. If I need to transfer to another WIC
Program, I authorize the release of this information to the transferring WIC Program. All information is considered confidential.
YOUR SIGNATURE: ___________________________________________
Health Care Provider: Please complete this section.
PRENATAL OR POSTPARTUM:
WEIGHT and HEIGHT must be less than 60 days old on the date
Gravida _______ Para_______ Multi Fetal____________
of the WIC appointment: _____/_____/_____
Date:
Pregravid Weight __________pounds
Date Taken:
Current Weight__________pounds
_____/_____/_____
EDD _____/_____/_____
_____/_____/_____
Prenatal Care Began _____/_____/_____
Current Height___________ inches
□
th
Fetal Weight <10
Percentile for Gestational Age
HEMATOLOGY:
BREASTFEEDING/POSTPARTUM: Most Recent Pregnancy
Date Taken:
Hgb ______gm/dL OR Hct______%
_____/_____/_____
Date of Delivery/(Termination, if any) _____/_____/_____
Blood Lead __________mcg/dL
_____/_____/_____
(Optional)
Total Weight Gained______pounds Weeks Gestation______
•Bloodwork must be taken during current pregnancy.
•Bloodwork must be taken after delivery for Breastfeeding/ Postpartum
Current Infant’s Birth Weight ______lb ______oz OR ______kg
Women.
SPECIFIC MEDICAL DIAGNOSIS OR NUTRITIONAL/HEALTH RISKS including ICD‐9 code
Provider's Name (Please Print):
Signature of Health Care Provider
Title:
Medical Office/Clinic:
Street:
City:
Zip:
Phone #:
Fax #:
Date:
______/______/______
Send Completed Form To:
DOH‐799 (10/08) This institution is an equal opportunity provider.
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