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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 – 10 XR 6/2020 WIC-10 (7/2020) 37433_WIC_Ctad_FIN2.indd 8 37433_WIC_Ctad_FIN2.indd 8 7/31/20 3:00 PM 7/31/20 3:00 PM