<p>WIC Medical Referral Form for Women and Infants Massachusetts WIC Nutrition Program Mother’s name: Infant’s name: Infant’s DOB:</p><p>I authorize WIC to provide this form to: (Name of Health Center/Hospital/Clinician) For completing medical information and returning to the WIC Program.</p><p>Applicant/Parent/Guardian’s Signature: Date:</p><p>Clinician: Please complete this section – WIC eligibility will depend on this information. </p><p>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 %</p><p>For Postpartum Women Date of delivery / termination __ / __ / __ Vaginal ___ C/S ___ Weeks gestation ___ Weight at labor ___ lb Postpartum weight ___ lbs Height ___ ft. ___ in.</p><p>For postpartum women, blood must be taken after delivery. One blood test required Date taken: HGB gm/dL Or HCT %</p><p>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</p><p>First</p><p>Please note all that apply: Woman - Hypertension - Diabetes/gestational diabetes - Smoking - Substance abuse, ______- Eating disorder, ______- Chronic asthma - Iron deficiency anemia - Depression </p><p>- Please refer to Breastfeeding Support Group - Please refer to Breastfeeding Peer Counselor Program</p><p>Infant Feeding Comments:______</p><p>Woman / Infant - Infectious disease - Congenital anomaly - Food allergy or intolerance - Rx medication - Other medical concerns:</p><p>Please send a copy of the WIC assessment to:</p><p>Signature of clinician Clinician’s name (please print) date Phone fax</p><p>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.</p><p>For WIC use Initials Date rec’d Appt. Appt. WIC# (W) WIC# (I) #106, Rev, 2017</p>