NEW JERSEY WIC HEALTH CARE REFERRAL

FOR

PREGNANT WOMAN

BREASTFEEDING WOMAN (Up to 1 Year Postpartum)

NON-BREASTFEEDING WOMAN (Up to 6 Months Postpartum)
Name

Birthdate

/ /
Address

Telephone Number

Women, infants and children MUST be present at every WIC certification appointment.

Bring:

∙Proof of your family's income

∙Proof of where you live

∙Proof of ID for every person

∙Health care referral form filled out

∙Immunization records of infant/child

CALL for an appointment with WIC office checked:

(Healthcare provider:

Check WIC office for patient.)

Burlington County

609-267-4304

Children’s Home Society

of NJ

609-498-7755

East Orange

973-395-8960 (8963)

Gloucester County

856-218-4116

Jersey City

201-547-6842

Newark

973-733-7628

North Hudson

201-866-4700

NORWESCAP

908-454-1210

Ocean County

732-341-9700 X 7520

Passaic

973-365-5620

Plainfield

908-753-3397

Rutgers

973-972-3416

St. Joseph

973-754-4575/4730

TriCounty/Gateway CAP

Main Office:

856-451-5600

Atlantic Office:

609‑246‑7767

Camden Office:

856‑225‑5050

Trinitas

908-994-5141

VNA

732-471-9301

OR

STATEWIDE

1-800-328-3838 (24 Hrs.)
ANTHROPOMETRIC AND LABORATORY DATA

Height and weight measurements must be taken <30 days prior to WIC appointment.

At least ONE blood test of Hemoglobin, Hematocrit or Erythrocyte Protoporphyrin (EP) is needed to determine nutritional risk of all women. The blood test must be taken <90 days prior to WIC appointment.

PREGNANT WOMEN need blood test which was done during pregnancy.

POSTPARTUM WOMEN (breastfeeding and non-breastfeeding) need blood test which was done after delivery.
Blood Test Date

/ /	Hemoglobin

gm/dl	Hematocrit

%	EP

(g/dl	Lead (if available)

Other

Height

inches	Pre-Pregnancy Weight

lbs.
FIRST

PRENATAL

CHECK-UP	# Wks. Gest.

Measurement Date

/ /	Weight

lbs.	Blood Pressure

/ mm/Hg
MOST

RECENT

CHECK-UP	# Wks. Gest.

Measurement Date

/ /	Weight

lbs.	Blood Pressure

/ mm/Hg
MEDICAL HISTORY
Delivery Date

Estimated

/ /	Actual	Woman’s Weight Just Prior to Delivery

lbs.	# Weeks Gestation at Delivery

Date Last Pregnancy Ended

/ /	No. Previous Pregnancies

No. Previous Live Births

Check all of the following which apply and give a brief explanation:

Hx of low birth weight infant(s) (<5.5 lbs.)

Hx of premature infant(s) (<37 weeks gestation)

Hx of infant(s) >9 lbs at birth

Hx of miscarriage(s)/stillbirth(s)/abortion(s)

Hx of or planned C-section

Multiple pregnancy or recent multiple birth

Medical problems (e.g. Diabetes, Hypertension, Preeclampsia, Eclampsia)

Disability which may compromise adequacy of diet

Social or environmental condition which may compromise adequacy of diet

Substance use (e.g. alcohol, drugs, cigarettes, pica)

Vitamin/mineral supplement or medicine prescription

Special formula prescription and medical reason for its necessity

Other pertinent health/medical data

Explanation

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________
AUTHORIZATION RELEASE

I, the undersigned, give permission to my provider to give the WIC Program any required medical information.
Signature of Patient Being Referred	Insurance Carrier and Member ID Number

Signature of Physician or Health Professional	Date

Name and Address of Physician or Clinic (Print or Stamp)

Telephone Number:
WIC-41

APR 16	This institution is an equal opportunity provider.

WIC-41, WIC Health Care Referral for Women

WIC-41, WIC Health Care Referral, Women, WIC Services, WIC

EWhite

2016-03-31

NJDHSS