Form DHHS-2822A "Wic Nutrition Assessment for Pregnant Women" - North Carolina

What Is Form DHHS-2822A?

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

Form Details:

  • Released on October 1, 2012;
  • The latest edition provided by the North Carolina Department of Health and Human Services;
  • 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 DHHS-2822A by clicking the link below or browse more documents and templates provided by the North Carolina Department of Health and Human Services.

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Download Form DHHS-2822A "Wic Nutrition Assessment for Pregnant Women" - North Carolina

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1. Last Name
First Name
MI
N.C. Department of Health and Human Services
WIC NUTRITION ASSESSMENT & CARE PLAN
-
H
2. Patient Number
PREGNANT WOMEN
3. Date of Birth
 Certification
Month
Day
Year
 A95 Temporary Eligibility for Pregnant Women
4. Race
1. White
2. Black /African American
3. America Indian/Alaskan Native
4 Asian
Client age_________________________________  Client present
5. Hawaiian/Other Pacific Islander
6. Unknown
Ethnicity: Hispanic origin?
Yes
No
 Medicaid
 Other  None
Health Insurance
5. Sex
1. Male
2. Female
Health care provider _______________________________________
6. County of Residence
st
Date 1
prenatal visit __________________ EDC ________________
Address
Phone
Primary Language (if other than English)________________________
Name of Interpreter (if used)__________________________________
Household composition: # Adults
# Children
A95 Certifier Signature/Title/Date:
SUBJECTIVE AND OBJECTIVE INFORMATION
Mark
boxes that apply and document relevant details. Indicate when information is elsewhere in medical record.
 person(s) who smokes
 inadequate water source
 inadequate appliances
Household has:
 FNS (food stamps)
 food security issues
to store/cook food
 person w/ limited abilities
 in foster care /date ____________
 homeless
 a migrant
Client is:
 No client-reported problem
Pre-pregnancy weight _____________ Pre-pregnancy BMI ______________
Height ______________________
Weight ___________________
Date of measures_____________________
Hemoglobin __________Hematocrit__________Date of test__________
Blood lead__________Date of test__________
Pregnancy Hx:
Date (mm/yy)
Birth weight
Weeks gestation
Outcome / complications
 medical condition(s)
 oral health condition(s)
 nausea
 vomiting
 heartburn
 constipation
Has:
 Rx medications
 OTC medications
 prenatal vitamins
 tobacco
 alcohol
 illegal drugs
Uses:
 plans to breastfeed
 no plans to breastfeed
 is undecided
Plans for infant feeding:
 No client-reported problem
Usual eating pattern: ________________________________________________________________________________________
 skim
 1%
 2%
 whole
 none
 other (specify)
Type of milk usually consumed:
_______________________
:
Most
Some
Most
Some
Behaviors
(
frequency)
days
days
Rarely
days
days
Rarely
Is physically active
Eats out or eats take-out food
Eats fruits
Drinks sweet drinks: soda, tea, sports/juice drinks
Eats vegetables
Watches more than 2 hours of TV
Drinks water
Other / inappropriate nutrition behavior(s):
_____________________________________________
_____________________________________________
SUMMARY OF NUTRITION STATUS (includes nutrition problems and/or potential problems)
DHHS 2822A (10/2012) Nutrition Services Branch
page 1 of 2
1. Last Name
First Name
MI
N.C. Department of Health and Human Services
WIC NUTRITION ASSESSMENT & CARE PLAN
-
H
2. Patient Number
PREGNANT WOMEN
3. Date of Birth
 Certification
Month
Day
Year
 A95 Temporary Eligibility for Pregnant Women
4. Race
1. White
2. Black /African American
3. America Indian/Alaskan Native
4 Asian
Client age_________________________________  Client present
5. Hawaiian/Other Pacific Islander
6. Unknown
Ethnicity: Hispanic origin?
Yes
No
 Medicaid
 Other  None
Health Insurance
5. Sex
1. Male
2. Female
Health care provider _______________________________________
6. County of Residence
st
Date 1
prenatal visit __________________ EDC ________________
Address
Phone
Primary Language (if other than English)________________________
Name of Interpreter (if used)__________________________________
Household composition: # Adults
# Children
A95 Certifier Signature/Title/Date:
SUBJECTIVE AND OBJECTIVE INFORMATION
Mark
boxes that apply and document relevant details. Indicate when information is elsewhere in medical record.
 person(s) who smokes
 inadequate water source
 inadequate appliances
Household has:
 FNS (food stamps)
 food security issues
to store/cook food
 person w/ limited abilities
 in foster care /date ____________
 homeless
 a migrant
Client is:
 No client-reported problem
Pre-pregnancy weight _____________ Pre-pregnancy BMI ______________
Height ______________________
Weight ___________________
Date of measures_____________________
Hemoglobin __________Hematocrit__________Date of test__________
Blood lead__________Date of test__________
Pregnancy Hx:
Date (mm/yy)
Birth weight
Weeks gestation
Outcome / complications
 medical condition(s)
 oral health condition(s)
 nausea
 vomiting
 heartburn
 constipation
Has:
 Rx medications
 OTC medications
 prenatal vitamins
 tobacco
 alcohol
 illegal drugs
Uses:
 plans to breastfeed
 no plans to breastfeed
 is undecided
Plans for infant feeding:
 No client-reported problem
Usual eating pattern: ________________________________________________________________________________________
 skim
 1%
 2%
 whole
 none
 other (specify)
Type of milk usually consumed:
_______________________
:
Most
Some
Most
Some
Behaviors
(
frequency)
days
days
Rarely
days
days
Rarely
Is physically active
Eats out or eats take-out food
Eats fruits
Drinks sweet drinks: soda, tea, sports/juice drinks
Eats vegetables
Watches more than 2 hours of TV
Drinks water
Other / inappropriate nutrition behavior(s):
_____________________________________________
_____________________________________________
SUMMARY OF NUTRITION STATUS (includes nutrition problems and/or potential problems)
DHHS 2822A (10/2012) Nutrition Services Branch
page 1 of 2
Name:__________________________________________________________________
Date of Birth:______________
Identify WIC nutrition risk criteria (
all that apply):
A41 Underweight prior to pregnancy
A73 History of birth with nutrition-related congenital
A01 Cancer
(BMI <18.5)
or birth defect
A02 Celiac disease
A45 Overweight prior to pregnancy
A54 Pregnant woman currently breastfeeding
A03 Central nervous system disorders
(BMI > 25)
A55 Multifetal gestation
A04 Depression
A48 Low maternal weight gain
A56 Fetal growth restriction (FGR)
A05 Developmental, sensory or motor
A49 Maternal weight loss during pregnancy
A66 Hyperemesis gravidarum
disabilities interfering with ability to eat
A50 High maternal weight gain
A67 Gestational diabetes
A06 Diabetes mellitus
A22 Low hemoglobin/hematocrit
A68 History of gestational diabetes
A07 Drug-nutrient interactions
A23 Elevated blood lead (>10 ug/dL)
A69 History of preeclampsia
A08 Eating disorders
A74 Maternal smoking
A59 Inadequate prenatal health care
A19 Food allergies
A75 Alcohol and illegal drug use
A61 Dental problems
A20 Gastrointestinal disorders
th
A40 Current conception prior to 18
birthday
A79 Inappropriate nutrition practice(s)
A21 Genetic and congenital disorders
A43 High parity and young age
A64 Failure to meet Dietary Guidelines (Use only
A24 Hypertension and prehypertension
A44 Current conception < 16 months of delivery
when no other nutrition risk criteria apply.)
A25 Hypoglycemia
of infant > 500 gms or > 20 weeks gestation
A91 Homelessness
A26 Inborn errors of metabolism
A70 History of preterm delivery
A96 Migrancy
A27 Infectious diseases
A71 History of low birth weight
A90 Environmental tobacco smoke exposure
A28 Lactose intolerance
A52 History of > 2 spontaneous abortions or
A92 Limited ability for feeding decisions / preparing
A29 Nutrient deficiency diseases
history of fetal or neonatal death
food
A30 Other medical conditions
A72 History of birth of a large for gestational
A94 Entered / changed foster care home(s) in the
A33 Recent major surgery, trauma, burns
age infant
past 6 months
A34 Renal disease
A97 Recipient of abuse
A35 Thyroid disorders
PLAN OF NUTRITION CARE
CLIENT ACTION STEPS – Document at least one
EDUCATION – Check required topics if provided. List other topics if provided.
(1) behavior change or action that client identifies or
 Prenatal diet
 Breastfeeding
 Substance abuse
Required Topics:
agrees to.
REFERRALS – Check box of any referral made. Write in any not listed under “Other”.
 Medicaid
 Dentist
 PCM (Pregnancy Care Mgmt)
 FNS (food stamps)
 RD
 Breastfeeding Peer Counselor
 Health care provider
 Other(s) -specify
FOOD PACKAGE – Check type of food package assigned by CPA.
 Standard
 Modified (specify modifications) :
FOLLOW-UP – Document timeframe and plan for follow-up.
CPA Signature/Title/Date:
DATE
NOTES
DHHS 2822A (10/2012) Nutrition Services Branch
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