Free F-44024B - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-44024B (Rev. 04/09)

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

WIC FORMULA and MEDICAL NUTRITIONAL PRESCRIPTIONS / CLINICAL DATA INFANTS and CHILDREN (1 through 4 years of age)
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 special WICapproved formula for an infant, or a formula or medical nutritional for a child, complete Prescription sections 1, 2 and 3. Indicate additional concerns in the Growth/Nutrition/Health Concerns section, as appropriate.

Patient's First and Last Name _________________________________________ Birthdate (MM/DD/YY) ____________ Parent/Caregiver's First and Last Name ________________________________________________________________ CLINICAL DATA Infants Only: Birth weight _____________ Birth length ____________ Gestational age __________ E.D.D. _________________ If mother was not on WIC prenatally, prenatal nutrition-related health problems or relevant obstetrical history:
Gestational Diabetes Pregnancy-Induced Hypertension Hyperemesis Gravidarum Anemia Food allergy or intolerance: ________ _________________________________ Infectious disease: _______________ _________________________________ Chronic disease: ______________ _______________________________ Other nutrition-related health problem: _______________________________

Infants and Children: Weight ____________

Length/stature ___________

Recumbent

Standing

Date taken ______________

Hct ___% and/or Hgb ___ mg Date taken ___________

Blood Lead ________ mcg/dL Date taken ___________

PRESCRIPTION (Complete 1, 2 and 3; all are required for WIC provision of the prescription.) 1. Formula or Medical Nutritional prescribed: Infants and Children:
Similac NeoSure DHA & ARA Enfamil EnfaCare LIPIL Enfamil Nutramigen LIPIL Enfamil Nutramigen LIPIL w/ Enflora LGG Similac Alimentum DHA & ARA Enfamil Pregestimil LIPIL Enfamil AR LIPIL Similac PM 60/40 w/fiber w/fiber w/o fiber w/o fiber Neocate Infant or Neocate Infant DHA & ARA Elecare Unflavored Elecare Vanilla (1-4 yr olds only) Portagen EO28 Splash/Pediatric EO28 Neocate One+ Neocate Junior

Children:
Good Start Supreme w/DHA & ARA/Gentle Plus Good Start Supreme Soy w/DHA & ARA/Soy Plus Good Start Supreme Natural Cultures w/DHA & ARA/Protect Plus Good Start Supreme/Nurture Plus PediaSure: PediaSure Enteral:

2. Intended length of use: Number of months _____ 3. Medical diagnosis and ICD-9 code justifying the above formula or medical nutritional prescription:
Allergy [cow's milk protein, soy] (477.9) Autoimmune Disorder (279.4) Anemia (281.9) Congenital Heart Disease (746.9) Congenital Anomaly, Respiratory (748.9) Cleft Palate (749.0) Cleft Lip (749.1) Cerebral Palsy (343.9) Cystic Fibrosis (277.0) Developmental Sensory/Motor Delays (783.4) Gastroesophageal Reflux (580.81) Immunodeficiency (279.3) Inadequate Growth (783.4) Intestinal Malabsorption (579.9) Neuromuscular Disorder (358.9) Prematurity (765.1) Other diagnosis with ICD-9 code (required) ________________________

GROWTH/NUTRITION/HEALTH CONCERNS:

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 ____________________
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, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (800) 795-3272 or (202) 7206382 (TTY). USDA is an equal opportunity provider and employer.

LOCAL WIC PROJECT: