Page 4

4

_____ Compulsively ingesting non-food items (pica). _____ Inadequate vitamin/mineral supplementation recognized as essential by national public health policy. _____ Pregnant woman ingesting foods that could be contaminated with pathogenic micro-organisms.

1. How is your appetite?

Good

Fair

Poor 2. Are you taking vitamins? Yes

No 3. If so, what vitamins are you taking? ________________________________________________________________________ 4. How many servings of vegetables do you eat per day? 1-2 3-4

5 or more None 5. How many servings of fruit do you eat per day? 1-2 3-4

5 or more None 6. How many servings of dairy do you eat per day? 1-2 3-4

5 or more I do not eat dairy 7. Are you having any issues feeding your baby? Yes

No 8. Do you have any questions regarding infant formula? 9. How do you plan on feeding your infant? Breastfeeding Infant Formula Combination of Breastfeeding & Infant Formula Undecided at this time

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 – 8 XR 6/2020 WIC-08 (7/2020) 37433_WIC_Ctad_FIN2.indd 4 37433_WIC_Ctad_FIN2.indd 4 7/31/20 3:00 PM 7/31/20 3:00 PM