Free WIC Medical Nutritional Prescriptions and Clinical Data, F-44024A - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-44024A (Rev. 08/08)

STATE OF WISCONSIN Bureau of Community Health Promotion WIC Program, Federal Reg. 246

WIC MEDICAL NUTRITIONAL PRESCRIPTIONS / CLINICAL DATA PREGNANT, BREASTFEEDING AND NONBREASTFEEDING POSTPARTUM WOMEN
Completion of this form is voluntary. Personally identifiable information is used to determine WIC services (e.g., certification/enrollment and food package issuance) and may be disclosed to others only as allowed by state and federal laws. INSTRUCTIONS: To provide clinical data (to facilitate WIC enrollment), complete the Clinical Data section. To prescribe a WICapproved medical nutritional product, complete Prescription sections 1, 2 and 3. Indicate additional concerns or relevant obstetrical history in the Nutrition/Health Concerns/Relevant Obstetrical History section, as appropriate.

Patient's First and Last Name ______________________________________ Birthdate (MM/DD/YY) _______________ CLINICAL DATA Pregnant and Postpartum Women: Current Weight ________ Current Stature ________ Date taken ____________ Hct ____% and/or Hgb ____ mg Date taken ___________ Vitamin/Mineral Rx ___________________________ Pregnant Women: E.D.D. _______________ Current weeks gestation ________ Prepregnancy weight ___________ Postpartum Women: Delivery date ________________ Prepregnancy weight _________ Weight gained __________ If not on WIC prenatally, prenatal nutrition-related health problems or relevant obstetrical history: Gestational Diabetes Food allergy or intolerance: ____ Chronic disease: ______________ Pregnancy-Induced Hypertension _____________________________ _______________________________ Hyperemesis Gravidarum Infectious disease: ___________ Other nutrition-related health Anemia _____________________________ problem: _______________________

PRESCRIPTION (Complete 1, 2 and 3; all are required for WIC provision of the prescription.) 1. Medical Nutritional prescribed: Ensure: Regular Fiber Glucerna High Protein Plus Plus HN Boost: b Regular Fiber High Protein Plus 2. Intended length of use: Number of months _______ 3. Medical diagnosis and ICD-9 code justifying the above prescription: Hyperemesis Gravidarum (643) Low maternal weight gain (646.8) Gestational Diabetes (648.2) Prenatal weight loss (783.2) Multifetal gestation (651) Intestinal Malabsorption (579.9) NUTRITION/HEALTH CONCERNS/RELEVANT OBSTETRICAL HISTORY: Other diagnosis, with ICD-9 code (required): ______________________ _______________________________

SIGNATURE - Health Care Provider ______________________________________________ Date Signed ____________________
(Physician, Physician Assistant or Advanced Practice Nurse prescriber signature is required for prescriptions of the above formulas or medical foods.)

Printed Name of Health Care Provider ____________________________________________________________________________ Medical Office/Clinic __________________________________________________________________________________________ Address ________________________________________________________________ Telephone __________________________

LOCAL WIC PROJECT:

In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.