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WIC Child Screening and Medical Justification for Therapeutic Formulas Mobile App

The WIC Child Screening and Medical Justification for Therapeutic Formulas mobile app is designed to assist health care providers with completing the required documentation to assist in qualifying a child for the WIC program.

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Take a peek inside the WIC Child Screening and Medical Justification for Therapeutic Formulas Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    HEALTH CARE PROVIDER: The WIC Program, as a secondary payer, may provide therapeutic formulas to ...

  • Ico textbox

    WIC agency:

  • Ico textbox

    Phone:

  • Ico textbox

    CHILD’S NAME:

  • Ico date

    Date of birth:

  • Ico textbox

    Parent’s/Guardian’s name:

  • Ico textbox

    Family ID number:

  • Ico dropdown

    Nutritional Item

  • Ico statictext

    WIC REGISTERED DIETITIAN (RD) OR NUTRITIONIST COMPLETES THIS SECTION.

  • Ico integer

    Age

  • Ico textbox

    Duration

  • Ico multiline

    Reactions

  • Ico statictext

    (Questions for participant)

  • Ico statictext

    Which of the following does your child use:

  • Ico checkbox

    Cup

  • Ico checkbox

    Bottle (day/evening)

  • Ico checkbox

    Fingers

  • Ico checkbox

    Spoon

  • Ico checkbox

    Fork

  • Ico multiline

    Comments:

  • Ico multiline

    What new feeding skill would you like your child to develop?

  • Ico multiline

    What do you think about your child’s eating (type/food texture/amounts/preferences)?

  • Ico multiline

    Describe your child’s appetite:

  • Ico multiline

    How do you and your child feel about mealtimes?

  • Ico multiline

    How do you plan snacks/mealtimes?

  • Ico statictext

    (Check all that apply and specify.

  • Ico checkbox

    llness/nutrition-related condition?

  • Ico multiline

    Illness/nutrition-related condition?

  • ...and More!

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