DCH-1317, MI-WIC Infant Offline template

(Birth through 1 Year of Age)

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

section 2 – Anthropometric Data

lbs	oz	Unk
Birthweight	Completed Weeks of Gestation:

Height	Weight	Head Circum
in	1/16	Unk	lbs	oz	Unk	in	1/16	Unk
Date

section 3 – Parents’ Anthropometrics

Height	Weight
ft	in	lbs
Mother’s
Father’s

section 4 – Imms/Bloodwork

IMMS Status	Referral Action

Lead

Has child had a blood lead test? Yes No Unknown

Date	Sign	Number	WIC	Method

Bloodwork

Date	Non-WIC Data	Hgb/Hct	Re-Test	Notes	No Blood	Exemption Reasons

section 5 – Health/Medical

1. Does your child currently have any medical conditions? (check if diagnosed) Yes, specify No

2. What, if any, prescription medications does your child take? Medications No medications

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

4. Does your child have any problems with their teeth or gums? Yes No

5. How much, if any, screen time did your child have yesterday? 2 hours or less More than 2 hours None Unknown

section 6 – Nutrition History

1. What type of water do you give your child? (Assess for fluoride content) Water with fluoride Water without fluoride Other/Unknown None

2. What is your child’s vitamin D source? Vitamin D supplement 32 oz formula 32 oz milk Other adequate source Inadequate/None

3. What, if any, diagnosed food allergies does your child have? Allergies No Allergies

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

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

section 7 – infant feeding

1. Tell me about the types of food and drinks your baby typically has. Adding any food (cereal or other foods) or juice to the bottle Baby drinks sugar sweetened beverages Complementary foods or drinks before 6 months old Baby is offered complex foods that are difficult to swallow Baby eats foods that could contain hidden bacteria (including deli meats, cold hot dogs, and honey) Baby follows a special diet, excluding key nutrients Baby takes herbal supplements/teas No Concerns

2. What are some of the things you look for when trying to decide if your baby is getting enough to eat? Not looking for hunger or fullness cues Less than 4 dirty diapers per day (if child is 4 days - 2 months) Less than 6 wet diapers per day Less than 8 feedings per day (if child is less than 2 months old) If breastfeeding/chestfeeding, baby has a weak or ineffective suck If breastfeeding/chestfeeding, baby has difficulty latching Baby not satisfied after eating No Concerns

3. Tell me how you typically prepare and store your baby's human milk/formula. Routinely using a substitute for human milk/formula Using donor milk supplied by individual or the internet Does not have access to safe water to prepare formula Not following formula mixing instructions, Intentional dilution of formula Heating human milk/formula in microwave Reusing left over human milk/formula from one feeding to another Using human milk that was thawed >24 hours prior to feeding Does not have access to a refrigerator or freezer to store human milk/formula Routinely propping the bottles or putting baby to bed with bottle No Concerns

section 8 – Breastfeeding Information

1. Was this child ever fed human milk, even colostrum? Yes No Unknown/refused

2. Is this child currently being fed any human milk? Yes No

3. Has this child been fed anything other than human milk? (i.e., formula, water, infant cereal, etc.) Yes No

4. How old was this child when they were first fed something other than human milk? (i.e., formula, water, infant cereal, etc.) Age: Months Weeks Days Unknown/refused

5. How much and how often is this child being fed in a 24-hour period of time?

Times/24 hours	Ounces per feed
Number of feeds at breast/chest
Bottles of human milk
Bottles of formula

Total ounces of formula/24 hours:

6. How old was this child when they completely stopped breast/chestfeeding or being fed human milk? Age: Months Weeks Days Unknown/refused

Reason breast/chestfeeding ended 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

section 9 – 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 10 – 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 Doctor Dentist Other

section 11 – Food Prescription

Exclusively Breastfed Partially Breastfed (Formula ; number of oz ) Standard Infant Formula Specialty Formula Customized Food Package Formula Only CVB @ 9 months

section 12 – 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