Breastfeeding/post Partum Women Application Form - Wic Alaska
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1
2Breastfeeding/Post Partum Women Application
Today’s Date ___________________
___________________________________________________________________
_______________________
Last Name
First Name
Middle Initial
Birth Date
331,332,333
If receiving Medicaid, please provide Medicaid number: __________________ or SSN:________________________
Is this person Hispanic or Latino?
No
Yes
Select at least one of the following:
American Indian/Alaska Native
Asian
White
Black/African American
Native Hawaiian/Pacific Islander
WIC helps families with healthy food and nutrition choices.
How are you doing after having your baby? Please, tell us if you have any concerns.
_____________________________________________________________________________
_____________________________________________________________________________
1. Please, tell us if you see a doctor, dietitian or health
11. What problems, if any, do you have caring for yourself
care provider for medical or emotional reason(s), ex:
or your baby/children?
902
hypertension, pre-hypertension, pre-diabetes, diabetes,
Describe: ____________________________________
anemia or gastrointestinal disorders
.
____________________________________________
201, 302-304, 341-349, 351- 363
Describe: ___________________________________
12. Circle the type of milk you would like on your
___________________________________________
WIC checks or in your food box:
2. If you were in the hospital in the last 3 months, please,
Fresh
Fluid (UHT)
Evaporated
tell us why.
359
Soy
Lactose Reduced
Dry
355
____________________________________________
13. What concerns, if any, do you have about having
_____________________________________________
enough food to feed your family?
3. Have you been screened or referred for lead poisoning?
Comment: ____________________________________
No
Yes
211
_____________________________________________
4. Write the date of your last dental check-up ________
381
14. What was the actual date your baby was born?
5. Tell us if you have any problems eating any type of
_____________________________________________
food for any reason such as dental problems, food
15. What was your baby’s length at birth?______________
intolerances, food allergies or others.
353-355, 381
16. What was your baby’s weight at birth?______________
Describe: ____________________________________
17. At what Birthing Facility did you give birth?
_____________________________________________
_____________________________________________
6. Does anyone smoke cigarettes, cigars, or pipes
18. When did your Prenatal care begin?
anywhere inside your home?
No
Yes
904
_____________________________________________
7. Does your family stay in a shelter, a temporary home,
How are you feeding your baby?
19.
or in a place not usually used for sleeping?
Breastmilk
Breastmilk + Formula
Formula Only
No
Yes
801
20. If Breastfeeding, on what date did breastfeeding
8. Do you have a refrigerator, a stove that works and
begin?______________________________________
storage free from pests and harmful chemicals?
21. On a scale of 0 to 10, how confident are you about
No
Yes
801
breastfeeding your baby? (Circle a number)
9. Did a family member have a seasonal farming job with
0 1 2 3 4 5 6 7 8 9 10
Not Confident
Very Confident
a temporary home in the last 24 months?
How long do you plan to breastfeed? ____________
601
No
Yes
802
I breastfeed _____ times in 24 hours
601,602
10. Are you in a relationship with anyone who pushes, hits
Each feeding lasts ________ minutes
602
or threatens you in any way?
No
Yes
901
***To Be Completed by Health Care Provider (HCP)***
Medical date_________ Ht _____ Pre-Pregnancy Wt _______ (101, 111) Weight Before Delivery______ Current Wt _______ (133) Hgb /Hct ______(201)
Name of HCP verifying applicant lives in Alaska ___________________________________ID Verified by: Visual Recognition___/Other _______WIC
Name of CPA reviewing WIC application_________________________________________ Certification Date _______________________________
Rev 9/11 Breastfeeding and Post Partum Women Application
Thank You!
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