Form DH3075 "Florida Wic Program Medical Referral Form" - Florida

What Is Form DH3075?

This is a legal form that was released by the Florida Department of Health - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2016;
  • The latest edition provided by the Florida Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DH3075 by clicking the link below or browse more documents and templates provided by the Florida Department of Health.

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Download Form DH3075 "Florida Wic Program Medical Referral Form" - Florida

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Florida WIC Program Medical Referral Form
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 _____________________________
PLEASE PLACE OFFICE STAMP BELOW:
Date _________
Address:
Phone Number:
***Parent or Guardian: Please bring a copy of your baby’s/child’s shot record to the WIC office.***
This institution is an equal opportunity provider.
DH 3075, 1/16 Florida Department of Health, WIC Program
Florida WIC Program Medical Referral Form
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 _____________________________
PLEASE PLACE OFFICE STAMP BELOW:
Date _________
Address:
Phone Number:
***Parent or Guardian: Please bring a copy of your baby’s/child’s shot record to the WIC office.***
This institution is an equal opportunity provider.
DH 3075, 1/16 Florida Department of Health, WIC Program
Instructions for Completing the Florida WIC Program Medical Referral Form
All shaded areas must be completed in order for the form to be processed.
1.
Check (✓) YES if the client has been screened and is eligible for Healthy Start. Check (✓) NO if the client is not
eligible for Healthy Start. Leave blank if the client has not been screened. Note: Eligibility for Healthy Start does not
affect a client’s eligibility for WIC.
Complete the client’s name and birth date.
2.
3.
Optional Information: the client’s sex, mailing address, phone number, city, zip code, social security number, and the
parent’s or guardian’s name for infants and children.
4.
Complete the appropriate shaded section for the client.
Pregnant Women: Complete the height and weight measurements and the date they were taken. These
measurements are to be taken no more than 60 days before the client’s WIC appointment. (The WIC appointment
may be recorded at the top of the form.) Complete the hemoglobin or hematocrit value and the date the value
was taken. There is no limit on how old the bloodwork data can be, as long as the measurement was taken during
the current pregnancy. Complete the expected date of delivery, the date of the client’s first prenatal visit, and the
prepregnancy weight.
Breastfeeding Women (eligible up to one year after delivery) and Postpartum Women—Non-Breastfeeding
(eligible up to 6 months after delivery/termination of pregnancy): Complete the height and weight measurements
and the date they were taken. These measurements are to be taken no more than 60 days before the client’s WIC
appointment. (The WIC appointment may be recorded at the top of the form.) Complete the hemoglobin or hematocrit
value and the date the value was taken. There is no limit on how old the bloodwork data can be, as long as the
bloodwork is taken after delivery of the most recent pregnancy. Complete the actual date of delivery, the date of the
first prenatal visit, and the weight measurement at the last prenatal visit.
Infants and Children less than 24 months of age: Complete the infant’s birth weight and birth length. Complete
the current height and weight measurements and the date they were taken. These measurements are to be taken
no more than 60 days before the client’s WIC appointment. (The WIC appointment may be recorded at the top of the
form.) Complete the hemoglobin or hematocrit value and the date the value was taken. A bloodwork value is required
once during infancy between 6 to 12 months of age (preferably between 9 to 12 months of age) and once between 1
to 2 years of age (preferably 6 months from the infant bloodwork value).
Children 2 to 5 years of age: Complete the current height and weight measurements and the date they were
taken. These measurements are to be taken no more than 60 days before the client’s WIC appointment. (The WIC
appointment may be recorded at the top of the form.) Complete the hemoglobin or hematocrit value and the date the
value was taken. A bloodwork value is required once a year unless the value is abnormal
(< 11.1 hemoglobin or < 33% hematocrit), then a bloodwork value is required in 6 months.
5.
Check (✓) any health problem that you have identified. Even if you have not identified a health problem, refer the
client to the WIC program.
6.
If you would like a nutritionist to counsel your client on a specific diet, check the box and specify the diet prescription
or diet order requested.
7.
If possible, please provide a copy of the immunization record for infant and child clients.
Complete the shaded area at the bottom of the form with the signature of the health professional taking the
8.
measurement or his/her designee and the office address and phone number. Stamp the form with the office stamp or
the health professional’s stamp.
9.
Give this completed form to the client or parent/guardian to bring to the WIC certification appointment or mail/fax the
form to the local WIC agency address shown in the bottom left corner of the form.
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