Healthandnutrition Questionnaire - Pregnantwoman (Page 2 of 2) in pdf

Staff use only:

Have you seen your dentist yet during this pregnancy?

¨ No

§ Nutrition practices:

¨ Yes

42 65 66 88

¨ I would like to find a dentist

Do you have a cavity to be filled or tooth to be pulled?

¨ No

¨ Yes

Check any of the following that you are experiencing:

§ Topics discussed:

¨ Feeling sick to my stomach

¨ Diarrhea

¨ Constipation

¨ Eating all the time!

¨ Throwing up

¨ Food cravings

¨ Heartburn

¨ Cravings for things like ice, baking

¨ No appetite

soda, clay, or cornstarch

¨ None of the above

§ Ed materials given:

¨ None

Are you following a prescribed special diet, weight control diet, vegan or

¨ Guide to Healthy Baby

(Spangler)

macrobiotic way of eating?

¨ Loving Support material

¨ No

¨ After You Deliver

¨ Yes: please

¨ Deliver a Healthy Smile

describe:_____________________________________

¨ Other:

How many times a day do you usually eat? ______ # meals per day

______ # snacks per day

§ Referrals:

How would you describe your appetite? ¨ Good ¨ Fair

¨ Poor

¨ None

¨ HBKF…….¨ Declined

Do you ever drink raw or bulk tank milk or unpasteurized juice?

¨ Provider/medical home

¨ No

¨ _________________

¨ Yes

§ SMART plan is:

Do you eat fish more than 2 times a week?

¨ No

¨ Yes

Do you eat soft cheeses such as Brie, feta or Camembert?

¨ No

¨ Yes

Which group of foods below do you find most challenging to eat enough

of?

¨ Milk, yogurt, cheese

¨ Protein foods like: meat, fish, eggs, beans

§ Nutrition follow up/next steps:

¨ INCP

¨ Fruits

¨ 28 week recall

¨ Vegetables

¨ Phone call

¨ Bread, cereal, rice, pasta

¨ Weight check

¨ Other: ___________________________

¨ Clinic or office visit

¨ Invited to group/nutrition activity:

How would you describe your daily activity? (check one)

¨ very active (run, aerobics, chopping wood)

¨ Other:

¨ moderately active (brisk walking, biking, hiking)

¨ somewhat active (easy walking, light housework)

¨ not active (sit most of the day)

§ Food package: A F

Omissions:

I would like to learn more about……..

¨ Healthy snacks for pregnancy

¨ Oral health for pregnancy

_____________________________

¨ Breastfeeding my baby

¨ Food resources in my area

§ Staff signature & title

¨ Ways to stretch my food dollars ¨ Other:

_____________________________

¨ Breastpumps from WIC

§ Date of visit

Vermont WIC Program

Healthandnutrition Questionnaire - Pregnantwoman Page 2

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