Wic Health History For Breastfeeding Women And Postpartum 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
Resultados___________________________________
a No
a No sabe
(21)
Have you ever had a baby with a birth weight of nine pounds or more?
¿Ha tenido un bebé que pesó 9 libras o más?
a a Yes
a a No
a Sí
a No
(22, 49)
Was your baby born three or more weeks early?
¿Ha tenido un bebé que nació trés o más semanas antes de tiempo?
a a Yes
How many weeks? __________________________
a a No
a Sí ¿Cuántas semanas antes? _________________________
a No
(49)
Was your baby born with any health problems?
¿Nació su bebé con algún problema de salud?
a a Yes
a a No
a Sí
a No
If yes, explain ____________________________________________________________________________________________________________________
Si contestó sí, explique. _____________________________________________________________________________________________________________
(23)
Check all supplements you take.
Marque todos los suplementos que consume.
a a Prenatal vitamins/vitamins
a a Iron
a a Herbs
a a Calcium
a Vitaminas prenatales / Vitaminas
a Hierro
a Hierbas
a Calcio
a a Other ___________________________________________________________________________________
a a None
a Otro _____________________________________________________________________________________
a Ninguno
(30)
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 Ninguno
(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 Ninguno
(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
Last three months of this pregnancy
__________a day
________a week
a a None
Los últimos tres meses de 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
Last three months of this pregnancy
__________a day
________a week
a a None
Los últimos tres meses de 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 currently use.
Marque todas las drogas que usa.
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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