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How much weight do you think you should gain with this pregnancy? (in pounds)*

Have you seen a doctor for this pregnancy?*

Yes

No

Are you expecting twins, triplets, etc?*

Yes

No

Are you having any problems/complications with this pregnancy?

Heartburn
Nausea and vomiting
Gestational diabetes

High blood pressure
Constipation
Diarrhea

Weight loss
Other

Other problems/complications not on this list*

Do you have any medical, health or dental problems?*

Yes

No

Please check and describe all of the following you routinely use

All information given to the WIC Program is confidential.

Over-the-counter drugs (laxitives, pain killers, etc)*

Yes

No

Please list over-the-counter drugs you routinely use*

Prescription medication*

Yes

No

Please list prescription medication you routinely use*

Vitamin and/or mineral supplements*

Yes

No

Please list vitamin and/or mineral supplements you routinely use*

Herbs/Herbal Supplements (Echinacea, ginger, etc.)*

Yes

No

Please list herbs/herbal supplements you routinely use*

Tobacco*

Yes

No

Street drugs (Marijuana, cocaine, methamphetamines, etc.)*

Yes

No

Please list anything else that is not on this list

Have you had a blood lead test?*

Yes

No

Unsure

Where was the blood lead test performed?*

How much did you weigh before your pregnancy that just ended? (in pounds)*

Not including this time, how many times have you been pregnant?*

Not including this last time, how many times have you been pregnant?*

Are you currently breastfeeding a baby/child?*

Yes

No

Have you breastfed your baby at any time since the delivery?*

Yes, currently breastfeeding

Yes, but not now

No

Please check any of the following that were true with any of your previous pregnancies

Please check any of the following that were true about your pregnancy that just ended

Please list any complications that are not on this list.

What do you think about breastfeeding?

Are you experiencing any of the following situations? (Check all that apply)

What other situations are you currently experiencing?

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