Dh Form 3075 - Florida Wic Program Medical Referral Form (Page 2 of 2) in pdf

Instructions for Completing the Florida WIC Program Medical Referral Form

All shaded areas must be completed in order for the form to be processed.

Check (✓) YES if the client has been screened and is eligible for Healthy Start. Check (✓) NO if the client is not

eligible for Healthy Start. Leave blank if the client has not been screened. Note: Eligibility for Healthy Start does not

affect a client’s eligibility for WIC.

Complete the client’s name and birth date.

Optional Information: the client’s sex, mailing address, phone number, city, zip code, social security number, and the

parent’s or guardian’s name for infants and children.

Complete the appropriate shaded section for the client.

Pregnant Women: Complete the height and weight measurements and the date they were taken. These

measurements are to be taken no more than 60 days before the client’s WIC appointment. (The WIC appointment

may be recorded at the top of the form.) Complete the hemoglobin or hematocrit value and the date the value

was taken. There is no limit on how old the bloodwork data can be, as long as the measurement was taken during

the current pregnancy. Complete the expected date of delivery, the date of the client’s first prenatal visit, and the

prepregnancy weight.

Breastfeeding Women (eligible up to one year after delivery) and Postpartum Women—Non-Breastfeeding

(eligible up to 6 months after delivery/termination of pregnancy): Complete the height and weight measurements

and the date they were taken. These measurements are to be taken no more than 60 days before the client’s WIC

appointment. (The WIC appointment may be recorded at the top of the form.) Complete the hemoglobin or hematocrit

value and the date the value was taken. There is no limit on how old the bloodwork data can be, as long as the

bloodwork is taken after delivery of the most recent pregnancy. Complete the actual date of delivery, the date of the

first prenatal visit, and the weight measurement at the last prenatal visit.

Infants and Children less than 24 months of age: Complete the infant’s birth weight and birth length. Complete

the current height and weight measurements and the date they were taken. These measurements are to be taken

no more than 60 days before the client’s WIC appointment. (The WIC appointment may be recorded at the top of the

form.) Complete the hemoglobin or hematocrit value and the date the value was taken. A bloodwork value is required

once during infancy between 6 to 12 months of age (preferably between 9 to 12 months of age) and once between 1

to 2 years of age (preferably 6 months from the infant bloodwork value).

Children 2 to 5 years of age: Complete the current height and weight measurements and the date they were

taken. These measurements are to be taken no more than 60 days before the client’s WIC appointment. (The WIC

appointment may be recorded at the top of the form.) Complete the hemoglobin or hematocrit value and the date the

value was taken. A bloodwork value is required once a year unless the value is abnormal

(< 11.1 hemoglobin or < 33% hematocrit), then a bloodwork value is required in 6 months.

Check (✓) any health problem that you have identified. Even if you have not identified a health problem, refer the

client to the WIC program.

If you would like a nutritionist to counsel your client on a specific diet, check the box and specify the diet prescription

or diet order requested.

If possible, please provide a copy of the immunization record for infant and child clients.

Complete the shaded area at the bottom of the form with the signature of the health professional taking the

measurement or his/her designee and the office address and phone number. Stamp the form with the office stamp or

the health professional’s stamp.

Give this completed form to the client or parent/guardian to bring to the WIC certification appointment or mail/fax the

form to the local WIC agency address shown in the bottom left corner of the form.

Dh Form 3075 - Florida Wic Program Medical Referral Form Page 2