Form Doh-132 - Wic Medical Referral Form For Infants And Children
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3Date Mailed/
NEW YORK STATE DEPARTMENT OF HEALTH
For WIC
Date Rec’d
Given
Use:
DIVISION OF NUTRITION
Appt Date
WIC ID #
WIC MEDICAL REFERRAL FORM FOR
INFANTS and CHILDREN
Child’s Last Name (Print):__________________________________________ Child’s First Name: ___________________________________
_
Parent/Caretaker’s Name:_________________________________________ Street: ________________________ Apt: ________________
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City:_____________________________________ Zip:__________________ On WIC Before: Yes
_
No
Sex: M
F
Phone: ( ) ________ ‐ _______ Child's DOB: ______/______/______ Language(s) Spoken: __________________________________
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I authorize __________________________________________________(Health Care Provider) to release the information below to the WIC Program, and I authorize the WIC
Program to release information about my infant/child to this health care provider for the purposes of coordinating his/her health care. If I need to transfer to another WIC
Program, I authorize the release of this information to the transferring WIC Program. All information is considered confidential.
YOUR SIGNATURE: _________________________________________
Health Care Provider: Please complete this section.
BIRTH HISTORY:
SGA
(<10th Weight for Gestational Age)
WEIGHT and HEIGHT must be less than 60 days old on the date of the
WIC appointment _____/_____/_____
Date Taken:
Birth Weight ______lb ______oz OR _______kg
Current Weight _____lb _____oz OR _____kg
_____/_____/_____
Current Height/Length _____in OR ______cm
_____/_____/_____
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Birth Length ________in OR ________cm Weeks Gestation_________
Measurement Taken:
Standing
Recumbent (< 2 yrs)
HEMATOLOGY:
Date Taken:
Provide marker IMMUNIZATION dates or attach a copy of record.
Hgb __________gm/dL OR Hct_______ ______%
First
Second
Third
Fourth
Fifth
____/____/____
Hep
Blood Lead
__________ mcg/dL at one year of age
____/____/____
B
DTP/D
Tap
Blood Lead __________ mcg/dL at two years of age
____/____/____
MMR
SPECIFIC MEDICAL DIAGNOSIS OR NUTRITIONAL/HEALTH RISKS including ICD‐9 code
Provider's Name (Please Print):
Signature of Health Care Provider
Title:
Medical Office/Clinic:
Street:
City:
Zip:
Phone #:
Fax #:
Date: ______/______/______
Send Completed Form To:
DOH‐132 (10/08) This institution is an equal opportunity provider.
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