1. Last Name
First Name
MI
N.C. Department of Health and Human Services
WIC NUTRITION ASSESSMENT & CARE PLAN
-
H
2. Patient Number
PREGNANT WOMEN
3. Date of Birth
Certification
Month
Day
Year
A95 Temporary Eligibility for Pregnant Women
4. Race
1. White
2. Black /African American
3. America Indian/Alaskan Native
4 Asian
Client age_________________________________ Client present
5. Hawaiian/Other Pacific Islander
6. Unknown
Ethnicity: Hispanic origin?
Yes
No
Medicaid
Other None
Health Insurance
5. Sex
1. Male
2. Female
Health care provider _______________________________________
6. County of Residence
st
Date 1
prenatal visit __________________ EDC ________________
Address
Phone
Primary Language (if other than English)________________________
Name of Interpreter (if used)__________________________________
Household composition: # Adults
# Children
A95 Certifier Signature/Title/Date:
SUBJECTIVE AND OBJECTIVE INFORMATION
Mark
boxes that apply and document relevant details. Indicate when information is elsewhere in medical record.
person(s) who smokes
inadequate water source
inadequate appliances
Household has:
FNS (food stamps)
food security issues
to store/cook food
person w/ limited abilities
in foster care /date ____________
homeless
a migrant
Client is:
No client-reported problem
Pre-pregnancy weight _____________ Pre-pregnancy BMI ______________
Height ______________________
Weight ___________________
Date of measures_____________________
Hemoglobin __________Hematocrit__________Date of test__________
Blood lead__________Date of test__________
Pregnancy Hx:
Date (mm/yy)
Birth weight
Weeks gestation
Outcome / complications
medical condition(s)
oral health condition(s)
nausea
vomiting
heartburn
constipation
Has:
Rx medications
OTC medications
prenatal vitamins
tobacco
alcohol
illegal drugs
Uses:
plans to breastfeed
no plans to breastfeed
is undecided
Plans for infant feeding:
No client-reported problem
Usual eating pattern: ________________________________________________________________________________________
skim
1%
2%
whole
none
other (specify)
Type of milk usually consumed:
_______________________
:
Most
Some
Most
Some
Behaviors
(
frequency)
days
days
Rarely
days
days
Rarely
Is physically active
Eats out or eats take-out food
Eats fruits
Drinks sweet drinks: soda, tea, sports/juice drinks
Eats vegetables
Watches more than 2 hours of TV
Drinks water
Other / inappropriate nutrition behavior(s):
_____________________________________________
_____________________________________________
SUMMARY OF NUTRITION STATUS (includes nutrition problems and/or potential problems)
DHHS 2822A (10/2012) Nutrition Services Branch
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