Medical Referral Form for Women and Infants

WIC Medical Referral Form for Women and Infants Massachusetts WIC Nutrition Program Mother’s name: Infant’s name: Infant’s DOB:

I authorize WIC to provide this form to: (Name of Health Center/Hospital/Clinician) For completing medical information and returning to the WIC Program.

Applicant/Parent/Guardian’s Signature: Date:

Clinician: Please complete this section – WIC eligibility will depend on this information.

For Pregnant Women EDD __ / __ / __ Pregravid weight ______lb Date prenatal care began __ / __ / __ Gravida ___ Para ___ # TAB ___ # SAB___ Date of prior delivery / termination, if any: __ / __ / __ For pregnant women, blood must be taken for current pregnancy. One blood test required Date taken: HGB gm Or HCT %

For Postpartum Women Date of delivery / termination __ / __ / __ Vaginal ___ C/S ___ Weeks gestation ___ Weight at labor ___ lb Postpartum weight ___ lbs Height ___ ft. ___ in.

For postpartum women, blood must be taken after delivery. One blood test required Date taken: HGB gm/dL Or HCT %

For infant: Birth weight lb oz Birth length in Current weight lb oz Current length in Date Update immunization book or attach copy of record or give dates: Hep B

Please note all that apply: Woman - Hypertension - Diabetes/gestational diabetes - Smoking - Substance abuse, ______- Eating disorder, ______- Chronic asthma - Iron deficiency anemia - Depression

- Please refer to Breastfeeding Support Group - Please refer to Breastfeeding Peer Counselor Program

Infant Feeding Comments:______

Woman / Infant - Infectious disease - Congenital anomaly - Food allergy or intolerance - Rx medication - Other medical concerns:

Please send a copy of the WIC assessment to:

Signature of clinician Clinician’s name (please print) date Phone fax

For more WIC forms or for more information, please call WIC at 1-800-WIC-1007. You can also download many of the WIC’s forms for your patients on line at www.mass.gov/wic. USDA is an equal opportunity provider and employer.

For WIC use Initials Date rec’d Appt. Appt. WIC# (W) WIC# (I) #106, Rev, 2017