Minnesota Department of Health
WIC Program
Manual Certification – Women (Required Fields)
Date:
WIC ID:
Preg
BF
Non-BF
New Certification
Re-Certification
Demographics Information
Last Name:
Hispanic or Latino:
Race:
White
First Name :
Yes
No
Black/African American
Asian
Native Hawaiian/Pacific
American Indian/Alaskan
If American Indian/Alaskan Native please select one of the following:
Boise Forte
Mille Lacs
Fond du Lac
Grand Portage
Red Lake
Mdewankanton
Leech Lake
Lower Sioux
Other
Participant Declined
Upper Sioux
White Earth
Additional Info tabs 1 and 2
Household Smoking:
Yes
No
Education Level:
Medical Home (Name of Medical Clinic):
Health Information-Pregnant
Current Pregnancy Information
Expecting Multiple Births
Diabetes Mellitus
Expected Delivery Date:_____________________
Planned C-section
Gestational Diabetes
LMP Start Date:___________
Pre-Preg Weight:__________
Hypertension or Pre-hypertension
Date Prenatal Care Began:___________
Has Not Received Prenatal Care Yet
Requires Food Package III:
Yes
Date verified:__________________
No
Previous Pregnancy Information
Number of Pregnancies:__________
Number of Live Births:______
Number of Pregnancies 20 or more weeks:__________________
Number of WIC Pregnancies:____________
Date Last Pregnancy Ended:____________
Multivitamin Consumption (How often did she take a MV?)
How often the month prior to pregnancy?____________________
How often during pregnancy?____________________________
Cigarette Usage/Day
Alcohol Intake Drinks/Week
Per Day 3 months prior to Pregnancy:_______________
Per Day Currently:______________________________
Drinks/Week 3 months prior to Pregnancy:___________
Drinks/Week Currently:__________________________
Any Pregnancy History
Low Birth Weight
Premature Birth
Gestational Diabetes
Preeclampsia
Fetal or Neonatal Loss or 2 or more Spontaneous Abortions
Health Information-Post-partum
Postpartum Information
Actual Delivery Date:__________________
Weight at delivery:____________________
C-section Delivery
Weight Gained during Pregnancy:________
on WIC During Most Recent Pregnancy
Diabetes Mellitus
Hypertension or Pre-hypertension
Has Not Received Prenatal Care Yet
Requires Food Package III:
Yes
Date Prenatal Care Began:___________
No
Date verified:__________________
Cigarette Usage/Day
Per Day Last 3 months of Pregnancy:_____________
Per Day Currently:______________________________
Alcohol Intake Drinks/Week
Drinks/Week Last 3 months of Pregnancy:_________
Drinks/Week Currently:__________________________
THIS INSTITUTION IS AN EQUAL OPPORTUNITY PROVIDER.
1/19/11
Most Recent Pregnancy History
Low Birth Weight
Premature Birth
Multi-fetal Gestation
Fetal or Neonatal Loss or 2 or more Spontaneous Abortions
Any History Of
Diabetes Mellitus
Gestational Diabetes
Preeclampsia
Infant(s) Born from this Pregnancy (this info needs to be gathered for each infant if multiples)
Infant Status at Birth:
Live at Postpartum Visit
Neonatal Death (live 0-28 Days)
Gender:
Female
In Foster Care?
Male
Was the infant ever breastfed:
Not Alive at Postpartum Visit
Yes
No
Yes
No
Stillborn, Miscarriage, or Abortion
Birth Weight: ___________ Birth Length: _________
Unknown
Breastfeeding Now:
Yes
No
If Yes, Date Breastfeeding verified:____________ If No, reason why stopped breastfeeding: _________________________________
Date Breastfeeding Began: ___________________ Date Breastfeeding Ended:____________________
Amount of Breastfeeding:
Fully Breastfeeding
Mostly-Breastfeeding
Some-Breastfeeding
Non-Breastfeeding
If not Fully Breastfeeding, Date Supplemental Feeding Began:____________
Date Solids were introduced:_________________ OR
Not Applicable
Measurement Date:_________________________
Length/Height:_________inches_________1/8th
Weight:_______________ lbs __________ ounces
Height, Weight, and Blood
Date for Blood work: _____________________
Hgb:_________ HCT:______________
Reason Blood Work not Collected (write note):
Medical
Religious
Other
VENA Tab/Nutrition Assessment
Results of VENA Contact:
Nutrition Education/Materials Given
NE Topics covered and Materials Given:
Referrals
Referrals Given:
Food Package:
Comments
THIS INSTITUTION IS AN EQUAL OPPORTUNITY PROVIDER.
1/19/11
THIS INSTITUTION IS AN EQUAL OPPORTUNITY PROVIDER.
1/19/11