Breastfeeding/post Partum Women Application Form - Wic Alaska Page 2
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1
2Breastfeeding/Post Partum Women Application
If Formula
33. If you drank alcohol in the last three months of your
Did you ever breastfeed?
No
Yes
pregnancy, what was your alcohol intake?
If yes, I breastfed ____ days or ___weeks.
____________________ Drinks/Week
I introduced formula at ____weeks.
34. Check any drugs you are using.
372
22. On what date did breastfeeding end?_______________
Marijuana
Methadone
Cocaine
23. What is the reason that Breastfeeding was stopped?
Crank
Crack Methamphetamine
Speed
________________________________________________
Heroin
Other
None
Stopped Using
________________________________________________
If stopped using, when was the last time you used?
24. On a scale of 0 to 10, how well do think you are eating?
____________________________________________
(Circle a number)
Not Well 0 1 2
3
4
5
6
7
8 9 10 Very Well
35. How far apart were your last two pregnancies?
I usually eat ___meals /day and ___snacks/day.
__________________________________________
332
25. I eat fruits/vegetables:
1 cup/day or less
36. How many babies did you have during your last
2 cups/day
pregnancy? ____________
335
3 cups/day or more
26. Circle if you crave or eat:
37. How many times have you been pregnant? (do not
Ashes
Baking Soda
Dust
count this pregnancy) ____ times
Carpet Fibers
Chalk Cigarettes
Soil
Clay
Starch (laundry or corn starch)
38. How old are your children? ___ ___ ___ ___ ___
333
Paint Chips
Burnt Matches
Large quantities of ice and/or freezer frost
427.03
39. Check if you had any of the problems during your
_____________________________________________
recent pregnancy:
27. List any medication, vitamin, pre-natal vitamins,
Baby born 3 or more weeks early
311
mineral or herbal supplement you are taking.
357, 427.01
Baby, less than 5 pounds 9 oz. at birth
_____________________________________________
312
Miscarried – how many _____
_____________________________________________
321
Baby, 9 pounds or more at birth
337
If not daily, how often?______________________
427.04
Stillbirth – how many _____
321
_____________________________________________
Genetic or birth defects
339
28. Have you fasted, binged or vomited to control your
weight or followed a specific diet?
Had more than one baby- how many ______
335
No
Yes
Baby died before 1 month old
358/427.02
321
C-Section
359
Describe ________________________________
History of Gestational Diabetes
303
29. Do you smoke cigarettes, pipes or cigars?
History of Preeclampsia
304
No
Yes
371
40. How often do you feel down, depressed or hopeless?
361
If yes, how much a day_________________________
Never
Rarely
Sometimes
30. If you smoked in the last three months of your
Often
Always
pregnancy, what was your cigarette usage per day?
____________________________________________
41. What does your family do for fun?
31. Do you use smokeless, chewing tobacco or iqmik?
____________________________________________
No
Yes
___________________________________________
How many times per day? _______________________
How can WIC help your family today?
42.
32. Do you drink wine, beer or other alcoholic beverages?
___________________________________
No
Yes
372
___________________________________
If yes, how many drinks a day? _________________
___________________________________
If yes, how many days a week? _______________
Rev 9/11 Breastfeeding and Post Partum Women Application
Thank You!
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