Minnesota Department of Health WIC Program
Manual Certification – Infants and Children (Required Fields)
Date:
WIC ID:
Infant
Child
New Certification
Re-Certification
Mid-Certification
Demographics Information
Last Name:
First Name :
Hispanic or Latino:
Race:
White
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
Household Smoking:
Fond du Lac
Grand Portage
Red Lake
MdeWankanton
Yes
Leech Lake
Lower Sioux
Other
Participant Declined
Upper Sioux
White Earth
Additional Info tabs 1 and 2
TV/Viewing (>2 years old): number of hours per day:
______________
No
Medical Home (Name of Medical Clinic):
Education Level of Authorized Representative:
Authorized Rep Name:
Health Information
Unknown Birth Criteria:
Birth Weight: ____ Birth Length: ______
Premature Birth:
Yes
No
Weeks Gestation:______
Feeding Information
Was the infant ever breastfed:
Yes
Breastfeeding Now:
No
Yes
No
Unknown
If Yes, Date Breastfeeding verified:_____________ If No, reason why stopped breastfeeding:__________________________________
Amount of Breastfeeding: (Infants only – all children are non-breastfeeding in the system)
Fully Breastfeeding
Mostly-Breastfeeding
Some-Breastfeeding
Non-Breastfeeding
If not Fully Breastfeeding, Date Supplemental Feeding Began:____________
If Infant, Formula currently using:______________________________
Date Solids were introduced:_________
OR
Not Applicable
Requires FP III:
Yes
No
Date verified:__________________
Measurement Date:_________________________
Measurement Position:
Recumbent
Standing
Length/Height:_________inches_________1/8th
Weight:_______________ lbs __________ ounces
Medical Conditions:
Diabetes Mellitus
Hypertension/Prehypertenstion
Height, Weight, and Blood
Date for Blood work: _____________________
Hgb:_________ HCT:______________
Reason Blood Work not Collected (write note):
CPA determined not due
Medical
Religious
VENA Tab/Nutrition Assessment
Results of VENA Contact:
Nutrition Education/Materials Given
NE Topics Covered and Materials Given:
THIS INSTITUTION IS AN EQUAL OPPORTUNITY PROVIDER.
1/19/11
Referrals
Referrals Given:
Food Package:
Comments
THIS INSTITUTION IS AN EQUAL OPPORTUNITY PROVIDER.
1/19/11