DCH-1315, MI-WIC Postpartum Client Offline template

For certification and reference for mid-certification health evaluation appointments.

Michigan Department of Health and Human Services (MDHHS)

(Revised 12-24)

This form is to be filled out by WIC staff.

Today’s Date	Staff

section 1 – INFORMATION

Client Name

Birth Date	Expected Delivery Date	Actual Delivery/Pregnancy End Date

section 2 – Anthropometric Data/Bloodwork

Height in 1/16 Unk	Weight lbs oz Unk	Hgb/Hct	Re-Test	Notes	No Blood	Exemption Reasons
Date

What was your weight just before you became pregnant?

How much weight did you gain with this pregnancy?

section 3 – Health/Pregnancy

1. Did this pregnancy result in a live birth? Yes No Unknown/Refused

2. How many infants resulted from this pregnancy?

3. How many times have you been pregnant (including this pregnancy)?

4. How many times have you been pregnant for 20 or more weeks (not including this pregnancy)?

5. How many live births have you had (not including this delivery)?

6. During your most recent pregnancy, have you experienced any poor pregnancy or birth outcomes (stillbirth or neonatal death)? Yes No

7. Before this delivery, when did your previous pregnancy end (month/year)?

8. Tell me about any pregnancy or delivery related concerns you have had with your previous deliveries. Gestational Diabetes Mellitus (GDM) Infant 9 lbs or more Preeclampsia None apply

9. How many months pregnant were you when you had your first prenatal care visit with a medical provider? First month Second month Third month Fourth month Fifth month Sixth month Seventh month Eighth or ninth month Unknown No medical care

10. During your most recent pregnancy, were you told by your doctor that you had a. Gestational Diabetes Yes No Unknown b. High blood pressure Yes No Unknown

11. Tell me about any other pregnancy or delivery related concerns you or your medical provider have had with your most recent pregnancy/delivery. Preterm Delivery (< 37 weeks) Spina Bifida Preeclampsia Early Term Delivery (37 to < 39 weeks) Infant 9 lbs or more Birth Defect Low Birth Weight (Infant 5 lbs., 8 oz or less) C-section within the last 2 months None apply

section 4 – Health/Medical

1. Do you currently have any medical conditions (check if diagnosed)? Yes, specify No

2. What, if any, prescription medications do you take? Medications No medications

3. Do any of these medications impact your nutrition (upset stomach, poor taste, affect appetite)? Yes No

4. Do you have any problems with their teeth or gums? Yes No

5. In the month before this pregnancy, how many times a week did you take a multivitamin? None Less than 1 per week 1-3 per week 4 or more per week Unknown/Refused

6. In the last month, have you taken a prenatal or multivitamin? Yes No Unknown

7. Other than your prenatal/multivitamin and what has been prescribed by your doctor, are you taking any other vitamins/minerals, herbal supplements, or teas? Yes No Unknown

8. In the past year, have you used any products containing nicotine, tobacco, marijuana, or any other drugs? Yes No Unknown

Last 3 months of pregnancy (answer only if #8 is yes) a. Smoked Cigarettes Yes. If yes, how many on an average day? No Unknown/Refused

b. Used any other forms of nicotine or tobacco? Yes No Unknown/Refused

c. Used marijuana in any form (smoke, vape, edibles, oils)? Yes No Unknown/Refused

d. Used any illegal substance? Yes No Unknown/Refused

e. Used prescription medications in a way that wasn’t prescribed or that weren’t prescribed to you? Yes No Unknown/Refused

Current (answer only if #8 is yes) a. Smoked Cigarettes? Yes. If yes, how many on an average day? No Unknown/Refused

b. Used any other forms of nicotine or tobacco? Yes No Unknown/Refused

c. Used marijuana in any form (smoke, vape, edibles, oils)? Yes No Unknown/Refused

d. Used any illegal substance? Yes No Unknown/Refused

e. Used prescription medications in a way that wasn’t prescribed or that weren’t prescribed to you? Yes No Unknown/Refused

9. In the 3 months before you got pregnant, did you drink alcohol? Yes. If yes, how much in an average week? Less than 1 per week 1-2 per week 3-5 per week 6 or more per week Drank, but quantity unknown No Unknown/Refused

10. In the last 3 months of your pregnancy, did you drink alcohol? Yes. If yes, how much in an average week? Less than 1 per week 1-2 per week 3-5 per week 6 or more per week Drank, but quantity unknown No Unknown/Refused

11. Tell me about your current drinking habits Do not drink Drink less than 2 alcoholic drinks per day Drink 2 or more drinks per day Drank 5 or more drinks in one day in the last month Drank 5 or more drinks on 5 or more days in the last month

12. In the last week, have you felt down, depressed, or hopeless, or had little interest or pleasure in doing things? Never (if selected, skip to Section 5) Sometimes (1-3 times) More than half the time Everyday

a. In the last week, how often, if at all, have you felt scared or panicked for no reason? Never Sometimes (1-3 times) More than half the time Everyday

b. In the last week, how often, if at all, have you been so unhappy that you have cried? Never Sometimes (1-3 times) More than half the time Everyday

c. In the last week, have you had any thoughts of harming yourself or your child? Never Sometimes (1-3 times) More than half the time Everyday

section 5 – Nutrition History

1. What, if any, diagnosed food allergies do you have? Allergies No Allergies

2. Are there other foods you avoid or allergies you suspect? Yes, specify No

3. What, if any, special diet do you follow? Vegetarian diet Low calorie/weight loss diet Gluten Free Vegan diet Bariatric surgery Other Low carb/high protein diet Diabetic None

4. Do you eat any non-food items? Yes No Unknown/Refused

5. How would you describe your appetite? Good Fair Poor

6. Tell me about the foods you eat in a typical day. Fruits Vegetables Whole Grains Dairy Protein Sweet/Salty Snacks Fast Food/Restaurants Michigan Fish

7. What do you drink on most days? Water Pop Soy Beverage Diet Pop Other Milk Alternative (almond, oat, etc.) Fruit/Sports Drink 100% Juice Caffeinated/Energy Drinks Coffee/Tea Other Cow’s Milk Skim 1/2% 1% 2% Whole

8. How much physical activity do you get most days? None 15 minutes 30 minutes 1 hour more than 1 hour

9. Did you provide MIHP services for this client during this visit? (STAFF ONLY) Yes No

section 6 – Breastfeeding Information

1. Did you ever provide any human milk, even colostrum, to your baby? (if no, skip to #3) Yes No

2. Are you currently breast/chestfeeding or expressing your milk? (if no, skip to #3) Yes No

a. If yes, who?

3. Had you planned on breast/chestfeeding? Yes No Unknown/Refused

a. If yes, can you tell me what changed? My baby had difficulty latching or nursing Breast milk alone did not satisfy my baby I thought my baby was not gaining enough weight My nipples were sore, cracked or bleeding or it was too painful I thought I was not producing enough milk, or my milk dried up I had too many other household duties I felt it was the right time to stop breastfeeding I got sick or I had to stop for medical reasons I went back to work I went back to school Lack of support My baby had an illness or medical condition Doctor recommended I supplement or wean Other Unknown

4. What is your breast/chestfeeding goal? (only for clients currently breast/chestfeeding)?

section 7 – Breastfeeding Assessment (only for clients currently breast/chestfeeding)

1. What medical conditions or medication concerns do you have that you think might affect breast/chestfeeding? Breast surgery/trauma Depression Hypothyroidism Living with HIV (Do NOT ask. Only check if Diabetes voluntarily shared by client) Polycystic Ovary Syndrome (PCOS) No medical conditions or medication concerns Medications Other

a. Would you be interested in talking with WIC lactation staff about how these might affect breast/ chestfeeding? Yes, and referred No, seeing non-WIC Level 3 or 4 staff No, lactation help declined

2. Tell me how breast/chestfeeding is going. Going great Have questions/concerns and need help

section 8 – Nutrition Education	WIC Program Explanation

Topic	Method	Behavior Change/Goal	Notes

Family Topic	Individual Topic	Planned NE

High Risk RD Counseling with Non-WIC RD Counseling Declined Schedule NCRD

Reason for declining or referring:

section 9 – referrals (C=Current, R=Referred, D=Discussed)

Family Referrals Health Insurance Medicaid Outreach/Programs SNAP/Food Stamps Other

Individual Referrals Breastfeeding MIHP Other Home Visiting Immunizations Registered Dietitian – WIC Smoking Cessation Doctor Dentist Other

section 10 – Food Prescription

Standard Food Package Yogurt 2 % Milk No Cheese Lactose-Free Milk Soy Beverage/No Cheese Food Package Customized Food Package WIC Eligible Nutritional Infant Foods Remove Food Items

section 11 – next appointment

Next Appointment Type(s) EDUO NCRD IEVAL BFEVAL CEVAL RECERT LAB Other

Best Appointment Day M T W TH F

Best Appointment Time AM PM Other

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.
This institution is an equal opportunity provider