HTML Preview Medical Referral Form page number 1.
Shaded areas must be completed. See instructions for completing this form on the reverse side.
Is this client eligible for Healthy Start? ❑ Yes ❑ No For WIC Office Use Only:
Date of WIC Certification Appointment ______________
Client’s Name __________________________________ Birth Date ________________ Sex M F
Address _______________________________________ Phone Number (______) _______-________
City ___________________________ Zip Code _______ Social Security # ________-______-________
Parent’s/Guardian’s Name __________________________________
(for infants and children only)
❑ For Pregnant Women
Height ______ inches Weight ______ lb Date Taken ____________ (no older than 60 days)
Hemoglobin _________ OR Hematocrit _________ Date Taken ____________ (must be during current pregnancy)
Expected Date of Delivery __________ Date of First Prenatal Visit __________ Prepregnancy Weight _________
❑ For Breastfeeding and Postpartum (Non-Breastfeeding) Women
Height ______ inches Weight ______ lb Date Taken ____________(no older than 60 days)
Hemoglobin _________ OR Hematocrit _________ Date Taken ____________ (must be in postpartum period)
Date of Delivery __________ Date of First Prenatal Visit __________ Weight at Last Prenatal Visit _________
❑ For Infants and Children less than 24 months of age
Birth Weight ______ lb ______ oz Birth Length _________ inches
Current Height ______ inches Current Weight ______ lb Date Taken ____________ (no older than 60 days)
Hemoglobin _________ OR Hematocrit _________ Date Taken ____________ (required once between 6 to 12 months
AND once between 12 to 24 months)
❑ For Children 2 to 5 years of age
Height ______ inches Weight ______ lb Date Taken ____________ (no older than 60 days)
Hemoglobin _________ OR Hematocrit _________ Date Taken ____________ (once a year unless value < 11.1 Hgb or
< 33% Hct, then required in 6 months)
✓ Check all that apply. Please refer your client to WIC, even if nothing is checked below. This information
assists the WIC nutritionist in determining eligibility, developing a nutrition care plan, and providing nutrition counseling. WIC staff
may need to contact you or your staff to obtain more detailed medical information prior to providing WIC services.
❑ Medical condition (specify) ❑ Food allergy (specify) ________________________
____________________________________ ❑ Current or potential breastfeeding complications
❑ High venous lead level (5 μg/dl or more) (specify) __________________________________
Lead level _______ Date Taken ____________ ❑ Other (specify) _____________________________
❑ Recent major surgery, trauma, burns (specify)
____________________________________
❑ Nutrition Counseling Requested – specify diet prescription/order ___________________________________
WIC Local Agency Address:
I refer this client for WIC eligibility determination:
Signature/Title of Health Professional _____________________________
Date _________ PLEASE PLACE OFFICE STAMP BELOW:
Address:
Phone Number:
***Parent or Guardian: Please bring a copy of your baby’s/child’s shot record to the WIC ofce.***
DH 3075, 1/16 Florida Department of Health, WIC Program
This institution is an equal opportunity provider.
Florida WIC Program Medical Referral Form