Wic Health History For Infants Form - Ohio Department Of Health
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1
2Location of CPA
HT
WT
BMI
HGB
Mom’s BMI
Dad’s BMI
Ohio Department of Health • Bureau of Nutrition Services
WIC Health History for Infants
Baby’s name
Today’s date
Your name
Your relationship to baby
(96)
Birthdate
Date baby was due
Birth weight
Birth length
(50)
(51, 59)
(52)
Baby’s doctor or clinic
Date of last doctor or clinic visit
Were you on WIC during this pregnancy?
a
a
Yes
No
(61)
Please answer the questions below
My baby breastfeeds
Every ____________ hours
or
______________ times a day and _____________ times a night
a
Not breastfed
(71, 75)
Check all that apply to your breastfed baby.
a
a
a
a
Weak suck
Slow weight gain
Problems latching on
My baby has no problems breastfeeding
a
a
Not breastfeeding
Other ________________________________________________________________________
(56, 74)
Did you ever breastfeed your baby?
a
a
Yes
No
Still breastfeeding?
a
a
Yes
No
Why did you stop?_____________________________________________
How old was your baby when you stopped? _______
Was your baby born three or more weeks early?
a
a
Yes How many weeks? _____________________
No
(50)
Check any health problems your baby has.
a
Colic
a
Reflux
a
Teeth/gums
a
Birth defects
a
Slow weight gain
a
Jaundice (yellow color)
a
Other _____________________________________________________________________
a
None
(56, 68, 91, 93, 94)
List your baby’s medicines.
a
None
(93)
Is your baby up to date on shots?
a
a
a
Yes
No
Don’t know
Has the doctor tested your baby’s blood for lead?
a
a
a
Yes Results
No
Don’t know
_________________________________________
(21)
Do you clean your baby’s gums or teeth?
a
a
Yes
No
Check all that your baby takes.
a
a
a
a
Vitamins (vitamin D)
Iron drops
Fluoride drops
Herbs
a
a
Other _____________________________________________________________________________
None
(30)
List your baby’s food allergies.
a
None
(93)
How many times a day is your baby’s diaper wet or dirty?
(74)
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OVER
HEA 4448 2/08
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