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_____ Routinely not providing dietary supplements recognized as essential by national public health policy when an infant’s diet

alone cannot meet nutrient requirements. 1. Do you have any concerns with your baby? Yes No 2. How are you feeding your baby? Breastfed Formula Fed Combination 3. If using formula, which appliances do you use to heat up formula? ______________________________________________

Family Alerts Screen Add: Family Alert

Participant Alert: _______________________________________________________ Start Date: __________________ End Date: ______________________________________________________________

Care Plan Screens Maintain Care Plan Goals

Family Goals (circle all that apply) Dairy Intake

Family Mealtimes Increase Fruits and Vegetables Healthy Snacks Physical Activity Iron Foods

Weaning

Smoke Exposure

Whole Grains Free Form Goals: _____________________________________________________________________________________________

Individual Goals Participant 1: _________________________________________ Dairy Intake

Family Mealtimes Increase Fruits and Vegetables Healthy Snacks Physical Activity Iron Foods

Weaning

Smoke Exposure

Whole Grains Free Form Goals: _____________________________________________________________________________________________ Family Class: __________________________________________ Method: ______________________________________________ Individual Class: _______________________________________ Method: _______________________________________________

Nutrition Education Family Individual Class Topic: ________________________________________

Nutrition Education Refusal Refusal Type: Family Individual

Date: _______________ Reason: ____________________________________________

Referral Program Program Name: ___________________________________________ Family Individual __________________________ Program Name: ___________________________________________ Family Individual __________________________ Program Name: ___________________________________________ Family Individual __________________________

Care Plan Summary Nutrition Assessment

_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

Entered by: ____________________________________________________________________

Issue Benefits Prescribe Food: Default Package Any Exceptions: _________________________________________________________________________ WIC 53 Category: ___________________________________ Subcategory: ______________________________________ Quantity: _______________________

WIC – 9 XR 6/2020 WIC-09 (7/2020) 37433_WIC_Ctad_FIN2.indd 12 37433_WIC_Ctad_FIN2.indd 12 7/31/20 3:00 PM 7/31/20 3:00 PM