Wic Nutrition Assessment & Care Plan Pregnant Women (Page 2 of 2) in pdf

Name:__________________________________________________________________

Date of Birth:______________



Identify WIC nutrition risk criteria (

all that apply):



A41 Underweight prior to pregnancy

A73 History of birth with nutrition-related congenital

A01 Cancer



(BMI <18.5)

or birth defect

A02 Celiac disease



A45 Overweight prior to pregnancy

A54 Pregnant woman currently breastfeeding

A03 Central nervous system disorders



(BMI > 25)

A55 Multifetal gestation

A04 Depression



A48 Low maternal weight gain

A56 Fetal growth restriction (FGR)

A05 Developmental, sensory or motor



A49 Maternal weight loss during pregnancy

A66 Hyperemesis gravidarum

disabilities interfering with ability to eat



A50 High maternal weight gain

A67 Gestational diabetes

A06 Diabetes mellitus



A22 Low hemoglobin/hematocrit

A68 History of gestational diabetes

A07 Drug-nutrient interactions



A23 Elevated blood lead (>10 ug/dL)

A69 History of preeclampsia

A08 Eating disorders



A74 Maternal smoking

A59 Inadequate prenatal health care

A19 Food allergies



A75 Alcohol and illegal drug use

A61 Dental problems

A20 Gastrointestinal disorders



A40 Current conception prior to 18

birthday

A79 Inappropriate nutrition practice(s)

A21 Genetic and congenital disorders



A43 High parity and young age

A64 Failure to meet Dietary Guidelines (Use only

A24 Hypertension and prehypertension



A44 Current conception < 16 months of delivery

when no other nutrition risk criteria apply.)

A25 Hypoglycemia



of infant > 500 gms or > 20 weeks gestation

A91 Homelessness

A26 Inborn errors of metabolism



A70 History of preterm delivery

A96 Migrancy

A27 Infectious diseases



A71 History of low birth weight

A90 Environmental tobacco smoke exposure

A28 Lactose intolerance



A52 History of > 2 spontaneous abortions or

A92 Limited ability for feeding decisions / preparing

A29 Nutrient deficiency diseases



history of fetal or neonatal death

food

A30 Other medical conditions



A72 History of birth of a large for gestational



A94 Entered / changed foster care home(s) in the

A33 Recent major surgery, trauma, burns

age infant



past 6 months

A34 Renal disease



A97 Recipient of abuse

A35 Thyroid disorders

PLAN OF NUTRITION CARE

CLIENT ACTION STEPS – Document at least one

EDUCATION – Check required topics if provided. List other topics if provided.

(1) behavior change or action that client identifies or

 Prenatal diet

 Breastfeeding

 Substance abuse

Required Topics:

agrees to.

REFERRALS – Check box of any referral made. Write in any not listed under “Other”.

 Medicaid

 Dentist

 PCM (Pregnancy Care Mgmt)

 FNS (food stamps)

 RD

 Breastfeeding Peer Counselor

 Health care provider

 Other(s) -specify

FOOD PACKAGE – Check type of food package assigned by CPA.

 Standard

 Modified (specify modifications) :

FOLLOW-UP – Document timeframe and plan for follow-up.

CPA Signature/Title/Date:

DATE

NOTES

DHHS 2822A (10/2012) Nutrition Services Branch

page 2 of 2

Wic Nutrition Assessment & Care Plan Pregnant Women Page 2

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