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Anthro/Lab Screen Height/Weight Measurement date: __ Height: ___________________ Weight: ______________ lb. ___________oz. Collected by: _________________ Source of Measures: _______________ Measurement Type: ________________ Gestational Age: _____________ Blood Work Blood work Date: _______________ Hgb: ______________ or Hct _________________ Collected by: _____________ Source of Measures: ________________ Exempt Reason: ________________ Deferred Reason: ____________________

Health Information Screen Infant/Child Health Information Birth Length: ________________in.

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: _____________________________________________________________________________________

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 feeding inappropriate beverages as the primary milk source. _____ Routinely feeding a child any sugar-containing fluids. _____ Routinely using nursing bottles, cups, or pacifiers improperly. _____ Routinely using feeding practices that disregard the developmental needs or stages of the child. _____ Feeding foods to a child that could be contaminated with harmful microorganisms. _____ Routinely feeding a diet very low in calories and/or essential nutrients. _____ Feeding dietary supplements with potentially harmful consequences. _____ Routinely not providing dietary supplements recognized as essential by national public health policy when a child’s diet

alone cannot meet nutrient requirements. _____ Routine ingestion of nonfood items (pica). 1. How many meals does your child eat per day? __________________ 2. How many snacks does your child eat per day? __________________ 3. How many servings of vegetables does your child eat per day? ____________ 4. How many servings of fruits does your child eat per day (includes 100% juice)? ________________ 5. What types of beverages does your child usually drink (list all that apply) _________________________________________

Family Alerts Screen Add Family Alert Participant Alert: ______________________________________________________ Start Date: _________________ End Date: __________________________

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