Wic Health History For Breastfeeding Women And Postpartum Women Form - Ohio Department Of Health
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1
2Location of CPA
HT
WT
BMI
HGB
Ohio Department of Health • Bureau of Nutrition Services
WIC Health History for Breastfeeding Women and Postpartum Women
Name
Today’s date
Age
(39, 40)
Date this pregnancy ended
What was your due date?
Your weight at delivery
Your weight before pregnancy
(49)
(11)
Check one
a
a
a
a
a
live birth _______pounds _______ounces
stillbirth
miscarriage
abortion
infant death
(22, 45, 49)
Number of past pregnancies
How many ended in live birth?
Date previous pregnancy ended
(39)
(42)
(43)
Prenatal doctor or clinic
Date of last doctor visit
If you are currently breastfeeding, fill out Sections 1 and 2. If you are not currently breastfeeding fill out Section 2.
Section 1
My baby breastfeeds
every ________hours or ________times a day and _______times a night
How long on each side? ___________________
(70)
If your baby gets bottles
What is in the bottle? __________________________________________
How often? _____________________________
Do you have problems with
a
a
a
a
a
Let down
Hot, hard breasts
Latch
Pain in your breasts
Sore nipples
a
a
Other
No problems
____________________________________________________________________
(74)
How long do you want to breastfeed your baby?
Are you going back to work or school?
a
a
Yes When? _______________________________
No
What kind of support for breastfeeding do you have at home?
Would you like more breastfeeding help?
a
a
Yes
No
Section 2
Did you ever breastfeed your baby?
a
a
a
Still breastfeeding
Yes
No
Why did you stop?
How old was your baby when you stopped?
_____________________________________________________________
_________
Did you have a C-section?
a
a
Yes
No
(93)
List any problems you have had.
With this pregnancy
_________________________________________________________________________________________________
a
With past pregnancies
None
_______________________________________________________________________________________________
(44)
Check any health problems you currently have.
a
a
a
a
a
Diabetes
Depression
Dental
High blood pressure
Lactose intolerance
a
a
Other _____________________________________________________________________
None
(91, 93, 94)
List any medicines you take.
(93)
☛
OVER
HEA 4449 2/08
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