Form Doh 961-136 - Washington Wic Medical Documentation Form For Children 1-5 Years printable pdf download

Washington WIC Medical Documentation Form - Children 1 – 5 years

Child’s Name _______________________________________________

Date of Birth _____________________

Caregiver’s Name ____________________________________

1. Medical diagnosis:

Check a qualifying medical diagnosis:

 Gastrointestinal disorders/malabsorption syndrome

 Lactose intolerance

 Preterm or early delivery ≤ 38 weeks gestation (<2 years old)

 Milk protein allergy

 Low birth weight ≤ 5 lbs. 8 oz. (<2 years old)

 Failure to thrive

 Metabolic disorders/inborn errors in metabolism

 Abnormal weight loss/underweight

 Severe food allergies: must explain under Notes

 Immune system disorders

 Other medical diagnosis or condition that impacts nutritional status: must explain under Notes

Notes:

2. Prescribe formula

(Requests for special formulas are subject to WIC approval)

A. Formula

 Similac Advance (20 kcal/oz.)

 Similac Spit-Up (19 kcal/oz.)

 Enfamil Nutramigen

 Good Start Soy (20 kcal/oz.)

 Similac Total Comfort (19kcal/oz.)

 Gerber Extensive HA

 Similac Sensitive (19 kcal/oz.)

 Similac Alimentum

Six month time limit

 PediaSure

 Similac NeoSure (22 kcal/oz.)

 Enfamil EnfaCare (22 kcal/oz.)

B. Prescribe amount:

 Allow up to maximum amount, WIC staff and caregiver will determine amount OR

_____ Ounces per day (not to exceed the maximum amount of formula allowed by WIC)

Special instructions:

3. Length of time

 3 months

 6 months

 12 months

 Other:_______(not to exceed 12 months)

4. WIC supplemental foods:

Unless indicated below, WIC will provide all supplemental foods.



WIC dietitian to determine type and amount of supplemental foods, and length of time (if Yes; go to Box 5)



No eggs

No cheese

No tofu

 No peanut butter

 No yogurt

 No soy beverage

 No dried beans, peas, lentils

 No cow milk

 No goat milk

 No canned beans

 No juice

 No fruits and vegetables

 No breakfast cereal

 No whole wheat bread or other whole grains



Give infant cereal in lieu of breakfast cereal

Give infants fruits/vegetables in lieu of fruit/vegetable check

D. WIC issues whole milk to children 12-23 months and nonfat or 1% milk to children older than 23 months.

Child is > 23 months and needs:  Whole milk or  2% milk Must include a diagnosis in Box 1

Child is 12 – 23 months and needs:  2% milk Must include a diagnosis in Box 1

5. Healthcare provider information

Name: _______________________________________________________________________Date:________________

Print or Stamp

Signature: ___________________________________ Phone: (______)____________Fax: (______)_______________

6. Release of information – signed by caregiver

I authorize Washington WIC staff to talk to my health care provider about my child’s health and nutrition needs. This authorization is good

for the length of this certification. I understand that I may cancel this authorization at any time by written request to WIC staff. This

release isn’t a condition of WIC eligibility. This release doesn’t include these conditions: sexually transmitted infections, mental health

concerns and chemical dependencies.

_____________________________________________________________________ _________________________

Caregiver Signature

Date

_____________________________________________________________________

Printed name

WIC Clinic:

_________________________________

Phone: _________________ Fax: _____________________

See back for instructions. Questions? Call the child’s WIC clinic or the Washington State Nutrition Program at 1-800-841-1410.

More information can be found at:

BREASTFED BABIES ARE HEALTHIER. WIC SUPPORTS BREASTFEEDING

DOH 961-136 October 2017

Form Doh 961-136 - Washington Wic Medical Documentation Form For Children 1-5 Years

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