Wic Health History For Pregnant 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 Pregnant Women
Name
Today’s date
Age
(39,40)
Your due date is
Weight before pregnancy Number of past pregnancies Number of live births
Date last pregnancy ended
(12,13)
(39)
(45)
(43)
Prenatal doctor or clinic
How far along were you at your first doctor visit for this pregnancy?
(16)
If this is not your first pregnancy, fill out Sections 1 and 2. Fill out Section 2 if this is your first pregnancy.
Section 1
Are you breastfeeding now?
a
a
Yes
No
(69)
Have you ever breastfed?
a
a
Yes
No
If yes, why did you stop?__________________________________________
How old was your baby when you stopped? ________
Have you had any problems with past pregnancies?
a
a
Yes
No
(44,45)
If yes, list __________________________________________________________________________________________________
Check if you ever had a baby with one of these birth weights.
a
a
a
5 pounds and 8 ounces or less
9 pounds or more
Neither
(22, 49)
Have you ever had a baby born three or more weeks early?
a
Y
a
es How many weeks?
No
______________
(49)
Have you ever had a baby born with any health problems?
a
a
Yes
No
(23)
If yes, explain_______________________________________________________________________________________________
Section 2
Check any problems you are having with this pregnancy.
a
a
a
a
a
a
Heartburn
Poor appetite
Vomiting
Diarrhea
Nausea
Constipation
a
a
Other _____________________________________________________________________
None
(44)
Check any of your health problems.
a
a
a
a
a
Diabetes
Depression
Dental
High blood pressure
Lactose Intolerance
a
a
Other _____________________________________________________________________
None
(44, 91, 93, 94)
Have you lost weight during this pregnancy?
a
a
Yes How much? ___________________________
No
(10)
List any medicines you take.
a
None
(93)
Check all supplements you take.
a
a
a
a
a
a
Prenatal vitamins
Vitamins
Iron
Herbs
Calcium
Folic acid
a
a
Other _____________________________________________________________________
None
(30)
☛
OVER
HEA 4455 2/08
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