Dh Form 3075 - Florida Wic Program Medical Referral Form
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2Florida WIC Program Medical Referral Form
Shaded areas must be completed.
See instructions for completing this form on the reverse side.
Is this client eligible for Healthy Start?
❑ Yes
❑ No
For WIC Office Use Only:
Date of WIC Certification Appointment ______________
Client’s Name __________________________________ Birth Date ________________
Sex
M
F
Address _______________________________________ Phone Number (______) _______-________
City ___________________________ Zip Code _______ Social Security # ________-______-________
Parent’s/Guardian’s Name __________________________________
(for infants and children only)
For Pregnant Women
❑
Height ______ inches
Weight ______ lb
Date Taken ____________ (no older than 60 days)
Hemoglobin _________ OR Hematocrit _________
Date Taken ____________ (must be during current pregnancy)
Expected Date of Delivery __________ Date of First Prenatal Visit __________ Prepregnancy Weight _________
For Breastfeeding and Postpartum (Non-Breastfeeding) Women
❑
Height ______ inches
Weight ______ lb
Date Taken ____________(no older than 60 days)
Hemoglobin _________ OR Hematocrit _________
Date Taken ____________ (must be in postpartum period)
Date of Delivery __________ Date of First Prenatal Visit __________
Weight at Last Prenatal Visit _________
For Infants and Children less than 24 months of age
❑
Birth Weight ______ lb ______ oz
Birth Length _________ inches
Current Height ______ inches
Current Weight ______ lb
Date Taken ____________ (no older than 60 days)
Hemoglobin _________ OR Hematocrit _________ Date Taken ____________ (required once between 6 to 12 months
AND once between 12 to 24 months)
For Children 2 to 5 years of age
❑
Height ______ inches
Weight ______ lb
Date Taken ____________ (no older than 60 days)
Hemoglobin _________ OR Hematocrit _________ Date Taken ____________ (once a year unless value < 11.1 Hgb or
< 33% Hct, then required in 6 months)
✓
Check all that apply. Please refer your client to WIC, even if nothing is checked below.
This information
assists the WIC nutritionist in determining eligibility, developing a nutrition care plan, and providing nutrition counseling. WIC staff
may need to contact you or your staff to obtain more detailed medical information prior to providing WIC services.
❑
Medical condition (specify)
❑
Food allergy (specify) ________________________
❑
____________________________________
Current or potential breastfeeding complications
❑
High venous lead level (5 μg/dl or more)
(specify) __________________________________
❑
Lead level _______ Date Taken ____________
Other (specify) _____________________________
❑
Recent major surgery, trauma, burns (specify)
____________________________________
❑
Nutrition Counseling Requested – specify diet prescription/order ___________________________________
WIC Local Agency Address:
I refer this client for WIC eligibility determination:
Signature/Title of Health Professional _____________________________
PLEASE PLACE OFFICE STAMP BELOW:
Date _________
Address:
Phone Number:
***Parent or Guardian: Please bring a copy of your baby’s/child’s shot record to the WIC office.***
This institution is an equal opportunity provider.
DH 3075, 1/16 Florida Department of Health, WIC Program
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Parent category: Medical