WIC Medical Referral Form
NEW YORK STATE DEPARTMENT OF HEALTH
WIC Program
WIC Medical Referral Form
This form may be used to refer patients to the WIC Program and to communicate changes
in patient health information. The information provided on this form will be used by a WIC
nutritionist to determine nutrition care and provide nutrition counseling.
WIC OFFICE USE
WIC ID
A separate form is required for each patient. Sections B, C and D must be completed by a
health care provider. See reverse side for additional instructions.
WIC LOCAL AGENCY STAMP
A. Patient Information
Patient Name_____________________________________________________ Date of Birth ____ /____ /____ Sex_________________________
Street Address_____________________________________________________________________________________ Apt. No.____________
City_____________________________________________ State______ ZIP____________ Phone ( _______ ) __________________________
Preferred Language(s) ______________________________________ Parent/Guardian Name _________________________________________
B. Patient Medical Information Health Care Provider: Please complete the section that is appropriate for the above named patient.
WOMAN
INFANT OR CHILD UP TO 24 MONTHS
CHILD 2 TO 5 YEARS
Current Height ______ in
Current Weight ______ lbs ______ oz
Date Taken ____ /____ /____
Birth Length _____ in or _____ cm
Birth Weight ____ lbs ____ oz or ____ kg
Weeks Gestation _____
Height/Length ____ in or ____ cm
Standing
Recumbent (If Unable to Stand)
Date Taken ____ /____ /____
HGB ______g/dL or HCT ______%
Date Taken ____ /____ /____
Current Length _____ in or _____ cm
Standing
Recumbent ( ................
................
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