Wic Health History For Pregnant Women Form - Ohio Department Of Health Page 2
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1
2Has the doctor tested your blood for lead?
¿Ha examinado su doctor el nivel de plomo en su sangre?
a a Yes
Results ___________________________________
a a No
a a Don’t know
a Sí
a Resultados ______________________________
a No
a No sabe
(21)
Are you on a special diet?
¿Está en una dieta especial?
a a Yes, your choice
a a Yes, from your doctor
a a No
a Sí, decisión suya
a Sí, decisión del médico
a No
(30, 35, 91, 93)
List your food allergies
Liste sus alergias a alimentos
a a None
a Ninguna
(93)
Check any of these non-food items that you e e a a t t or c c r r a a v v e e . .
Marque cualquiera de estas cosas que come o anhela comer.
a a Paint chips
a a Ice
a a Printed paper
a a Dirt/clay
a a Starch
a a Coffee grounds
a Cascaras de pintura a Hielo
a Papel con tinta
a Tierra o barro
a Almidón
a Borra o molinillo de café
a a Other_____________________________________________________________
a a None
a Otro ______________________________________________________________
a Ninguna
(30)
Check all that apply.
Marque lo que aplique.
a a Someone else shops for food.
a a I usually shop for food.
a a I usually do not eat at home.
a Otra persona compra los alimentos en mi casa. a Yo compró los alimentos.
a Yo usualmente no como en casa.
a a Someone else does the cooking.
a a I usually cook.
a a I live in a shelter, motel, or temporary place.
a Otra persona cocina en mi casa.
a Yo usualmente cocino.
a Yo vivo en un refugio (shelter), motel, o sitio temporero
a a I have a working stove or microwave and refrigerator in my home.
a Tengo una estufa o microonda y refigerador que trabaja en mi casa
a a I run out of money or food stamps to buy food.
a Me quedo sin dinero o estampillas para comprar alimentos.
(66, 95)
What do you think about your eating habits?
¿Qué piensa de sus hábitos de comer?
Name one or two things you do for physical activity or exercise.
Nombre una o dos cosas que hace como actividad física o ejercicio.
How many cigarettes, pipes, cigars do /did you smoke?
¿Cuántos cigarillos, pipas, cigarros fuma o fumaba?
Now
_________a day
_________a week
a a None
Ahora
_________al día
_________en semana
a ninguno
Anytime during this pregnancy
_________a day
_________a week
a a None
Cualquier momento durante este embarazo
_________al día
_________en semana
a ninguno
Three months before this pregnancy
_________a day
_________a week
a a None
Tres meses antes de este embarazo
_________al día
_________en semana
a ninguno
(46)
If anyone living in your home smokes, where do they smoke?
¿Si alguien en su casa fuma, donde fuman?
a a Inside
a a Outside
a a Car
a a No one smokes
a Adentro
a Afuera
a En el carro
a Nadie fuma
(46)
Check all alcoholic beverages you drink.
Marque todas las bebidas alcoholicas que toma.
a a Wine
a a Beer
a a Coolers
a a Liquor
a Vino
a Cerveza
a Coolers
a Licor
Now
_________a day
_________a week
a a None
Ahora
_________al día
_________en semana
a ninguno
Anytime during this pregnancy
_________a day
_________a week
a a None
Cualquier momento durante este embarazo
_________al día
_________en semana
a ninguno
Three months before this pregnancy
_________a day
_________a week
a a None
Tres meses antes de este embarazo
_________al día
_________en semana
a ninguno
(47, 66)
Check all drugs you used at any time during this pregnancy.
Marque todas las drogas que ha usado durante este embarazo.
a a Marijuana
a a Crack
a a Speed
a a LSD
a a Heroin
a Marijuana
a Crack
a Speed
a LSD
a Heroina
a a Crystal meth
a a Inhalants
a a Prescription drugs (misuse)
a Crystal meth
a Inhalantes
a Drogas recetadas (mal uso)
a a Other________________________________________________________________________________________
a a None
a Otro _________________________________________________________________________________________
a Ninguna
(48, 66, 93)
During the last six months, have you been physically, sexually or verbally abused?
¿Ha sido abusada fisicamente, sexualmente o verbalmente en los últimos seis meses?
a a Yes
a a No
a Sí
a No
(67)
Do you have any questions or concerns?
¿Tiene preguntas o preocupaciones?
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