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Anthro/Lab Screen Height/Weight Measurement date: _ Height: ___________________ Weight: ______________ lb. ___________oz. Collected by: _________________ Gestational Age: _____________ Blood Work Blood work Date: _____________ Hgb: ______________ or Hct _________________ Collected by: _____________ Exempt reason: __________________ Deferred reason_________________________

Health Information Screen Infant/child Health Information Birth Length: ________________in. ______________1/8’s

Hospital Discharge Date: ______________________________ Birth Weight: _______________lb. ______________oz.

Hospital Discharge Weight: ______________lb. ________ oz. Medical Home: _________________________ Last seen by Physician: __________________ Weeks Gestation: ____________ Multiple Gestation: Yes No Unknown Immunization Status: unknown up-to-date not up-to-date Medical Health Conditions_____________________________________

Breastfeeding Information Data Collection Date: _ __ Are you breastfeeding? Yes No Ever Breastfed? Yes No Breastfeeding Frequency: ______________________________ Age Infant Stopped Breastfeeding: _______________________ Reason Infant Stopped Breastfeeding: ___________________________________________________________ Age Supplement Was Given: ___________ No. of Wet Diapers/24 hr. Period: __________ No. of Stools/24 hr. Period: ____________ Do you give your baby any formula? Yes No How much formula do you give your infant in a 24-hour period? ozs. ________

Complications (breastfeeding): ________________________________________________________________

Eco-Social Assessment Screen Participant: Recipient of Abuse: Yes No Parent/Guardian/Caretaker limited abilities to feed: Yes No Maternal Intellectual Disability: Yes No Day Care Status: Yes No Physical Activity: ________ hrs. per day TV/Video Viewing: ____________ hrs. per day Mother participated in WIC during pregnancy: Yes No Unknown Mother was WIC eligible but did not participate: Yes No Mother abused alcohol or drugs during her most recent pregnancy: Yes No Unknown

Dietary & Health Screen Participant’s Inappropriate Nutrition Practices _____ Routinely using a substitute(s) for breast milk or for FDA approved iron-fortified formulas as the primary nutrient source

during the first year of life. _____ Routinely using nursing bottles or cups improperly. _____ Routinely offering complementary foods* or other substances that are inappropriate in type or timing. *Complementary

foods are any foods or beverages other than breast milk or infant formula. _____ Routinely using feeding practices that disregard the developmental needs or stage of the infant. _____ Feeding foods to an infant that could be contaminated with harmful microorganisms or toxins. _____ Routinely feeding inappropriately diluted formula. _____ Routinely limiting the frequency of nursing of the exclusively breastfed infant when breast milk is the sole source of

nutrients. _____ Routinely feeding a diet very low in calories and/or essential nutrients. _____ Routinely using inappropriate sanitation in preparation, handling, and storage of expressed breast milk or formula. _____ Feeding dietary supplements with potentially harmful consequences. 37433_WIC_Ctad_FIN2.indd 11 37433_WIC_Ctad_FIN2.indd 11 7/31/20 3:00 PM 7/31/20 3:00 PM