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3 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 Pre-Pregnancy Cigarettes Per Day Pre-pregnancy Weight ________lbs. _________ozs. ________ Three Months Prior to Pregnancy _____ Today Drinks Per Week ____________ Three Months Prior to Pregnancy _________ Last Trimester Pregnancy __________ Last Menstrual Period _________ Expected Delivery Date ____ 1st Prenatal Healthcare Visit __________ Number of Prenatal Healthcare Visits _________Date last seen by Physician Proof of Pregnancy ____________________________________ Number of Fetuses this Pregnancy __________ Gravida __________ Para __________ Medical Home: (e.g. ob/gyn, clinic) _______________________________________________________________________________ Dietary Supplement Taken Before Pregnancy: _______________________________________________________________________ Pregnancy Induced Health Conditions: _____________________________________________________________________________________________________ Health Conditions: _____________________________________________________________________________________________________ Currently Breastfeeding: Postpartum Labor Medications: ____________________________________________________________________________________________ Health Conditions: ____________________________________________________________________________________________ Pregnancy Induced Health Conditions: ____________________________________________________________________________ Delivery Date: __________________ Weight at Delivery ___________lbs. __________ ozs. Number of Fetuses this Pregnancy: __________ Gravida __________ Para __________ Medical Home (e.g. ob/gyn, clinic) ________________________________________________________________________________ Participant (infant’s name) ______________________________________________________________________________________ Outcome: Live Term Birth Fetal Death Miscarriage Neonatal Death Delivery Type: Vaginal Cesarean Weeks Gestation: __________ Birth Length: __________ Birth Weight: __________ 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 Limited Abilities to Feed-Self: Yes No Maternal Intellectual Disability: Yes No Dietary Supplement During Pregnancy Yes No Dietary & Health Screen Participant’s inappropriate Nutrition Practices _____ Consuming dietary supplements with potentially harmful consequences. _____ Consuming a diet very low in calories and/or essential nutrients or impaired caloric intake or absorption of essential nutrients following bariatric surgery. 37433_WIC_Ctad_FIN2.indd 3 37433_WIC_Ctad_FIN2.indd 3 7/31/20 3:00 PM 7/31/20 3:00 PM