Form Hea 4450 - Wic Health History For Children 1-5 Years - Ohio Department Of Health
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1
2Location of CPA
HT
WT
BMI
HGB
Mom’s BMI
Dad’s BMI
Ohio Department of Health • Bureau of Nutrition Services
WIC Health History for Children 1–5 Years
Child’s name
Today’s date
Your name
Your relationship to child
(96)
Child’s birth date
Birth weight
Birth length
(51, 59)
Child’s doctor or clinic
Date of last doctor or clinic visit
Please answer the questions below.
Did your child ever breastfeed?
a
a
a
a
Still breastfeeding
Yes
No
Don’t know
Why did you stop? _______________________________________________
How old was your child when you stopped? _______
Was your child born three or more weeks early?
a
a
Yes How many weeks? _____________
No
(50)
Please check all the health problems your child has.
a
a
a
a
a
Asthma
Depression
Teeth/gums
Birth defects
Lactose intolerant
a
a
Other _____________________________________________________________________________
None
(68, 91, 93, 94)
List your child’s medicines.
a
None
(93)
Is your child up to date on shots?
a
a
a
Yes
No
Don’t know
Has the doctor tested your child’s blood for lead?
a
a
a
Yes Results
No
Don’t know
_________________________________________
(21)
Has your child seen a dentist?
a
a
Yes
No
Do your child’s teeth get brushed?
a
a
Yes
No
Where do you get your water?
a
a
a
a
Well
City
Store bought
Other ________________________________________________
Check all that your child takes.
a
a
a
a
Vitamins
Herbs
Iron
Fluoride
a
a
Other _____________________________________________________________________________
None
(30)
List your child’s food allergies.
a
None
(93)
Is your child on a special diet?
a
a
a
Yes, your choice
Yes, from your doctor
No
(30, 35, 91, 93)
Is your child using formula?
a
a
Yes Which formula?
No
_____________________________________
(91, 93)
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OVER
HEA 4450 2/08
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