Prenatal Stuffs and Information Stuffs

8/19/2019 Prenatal Stuffs and Information Stuffs

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{\rtf\ansi\deff0{\fonttbl{\f0 Arial;}{\f1 Symbol;}{\f2 Wingdings;}}{\colortbl\red0\green0\blue0;\red230\green230\blue230;}\paperw12240\paperh15840\margl0\margr0\margt0\margb0\sectd\sbknone\sected\cols1\colno1\colw12240\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-216\par\pard\plain\li4790\sl-207\f0\fs22\cf0\b0\i0\ul0\strike0 Health and Nutrition Questionnaire\f0\fs22\cf0\b\i0\ul0\strike0 \par\pard\plain\li5635\sl-249\f0\fs22\cf0\b\i0\ul0\strike0 Pregnant Woman\f0\fs22\cf0\b0\i0\ul0\strike0 \par\pard\plain\li9297\sl-235\f0\fs20\cf0\b\i0\ul0\strike0 Staff use only:\par\sect\sected\sbknone\cols2\colno1\colw8330\colsr10\colno2\colw3900\pard\plain\li1583\sl-345\f0\fs20\charscalex96\cf0\b\i0\ul0\strike0 Your name: ________________________Baby is due:_____________\f0\fs20\charscalex96\cf0\b0\i0\ul0\strike0 \par\pard\plain\li0\sl-255\column\f1\fs20\cf0\chcbpat1\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\chcbpat1\b0\i0\ul0\strike0 Weeks gestation:____________\par\pard\plain\li0\sl-244\f1\fs20\cf0\chcbpat1\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\chcbpat1\b0\i0\ul0\strike0 Provider: __________________\par\sect\sected\sbknone\cols3\colno1\colw8330\colsr10\colno2\colw2010\colsr10\colno3\colw1880\pard\plain\sl-236\par\pard\plain\li1583\sl-189\f0\fs20\cf0\b0\i0\ul0\strike0 At today\u8217?s visit, we will talk about: \par\pard\plain\li0\sl-244\column\f1\fs20\cf0\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\b0\i0\ul0\strike0 Prenatal care: \par\pard\plain\li283\sl-224\f0\fs20\cf0\b0\i0\ul0\strike0 Dental home: \par\pard\plain\li0\sl-243\column\f0\fs20\cf0\b0\i0\ul0\strike0 Y \f0\fs20\cf0\b0\i0\ul0\strike0 N \f0\fs20\cf0\b0\i0\ul0\strike0 49 \par\pard\plain\li14\sl-225\f0\fs20\cf0\b0\i0\ul0\strike0 Y \f0\fs20\cf0\b0\i0\ul0\strike0 N\par\sect\sected\sbknone\cols2\colno1\colw8330\colsr10\colno2\colw3900\pard\plain\sl-219\par\pard\plain\li2088\sl-197\f2\fs20\cf0\b0\i0\ul0\strike0 \u172?\f0\fs20\cf0\b0\i

0\ul0\strike0 How are you feeling \f2\fs20\cf0\b0\i0\ul0\strike0 \u172?\f0\fs20\cf0\b0\i0\ul0\strike0 How much weight to gain \par\pard\plain\li2088\sl-230\f2\fs20\charscalex98\cf0\b0\i0\ul0\strike0 \u172?\f0\fs20\charscalex98\cf0\b0\i0\ul0\strike0 Healthy eating during pregnancy \f2\fs20\charscalex98\cf0\b0\i0\ul0\strike0 \u172?\f0\fs20\charscalex98\cf0\b0\i0\ul0\strike0 Questions you may have \par\pard\plain\sl-200\par\pard\plain\sl-302\par\pard\plain\li1583\sl-189\f0\fs20\charscalex89\cf0\b0\i0\ul0\strike0 How are you feeling about this pregnancy? ________________________ \par\pard\plain\sl-266\par\pard\plain\li1583\sl-189\f0\fs20\charscalex89\cf0\b0\i0\ul0\strike0 When was your first doctor or\f0\fs20\charscalex89\cf0\b0\i0\ul0\strike0 midwife visit for this pregnancy?________

_ \par\pard\plain\sl-271\par\pard\plain\li1583\sl-189\f0\fs20\charscalex89\cf0\b0\i0\ul0\strike0 What was your weight before you became pregnant?_______________

_ \par\pard\plain\sl-271\par\pard\plain\li1583\sl-189\f0\fs20\charscalex89\cf0\b

0\i0\ul0\strike0 How much weight have you been advised to gain?_________________ _ \par\pard\plain\sl-271\par\pard\plain\li1583\sl-189\f0\fs20\cf0\b0\i0\ul0\strike0 Have you ever had or do you now have a health or medical condition \par\pard\plain\li1583\sl-230\f0\fs20\cf0\b0\i0\ul0\strike0 such as asthma, diabetes, depression, epilepsy, etc? \par\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 No \par\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Yes If yes, please describe:_________________________ \par\pard\plain\sl-266\par\pard\plain\li1583\sl-189\f0\fs20\cf0\b0\i0\ul0\strike0 Do you take any of the following: (check all that apply) \par\pard\column\plain\sl-290\par\pard\plain\li0\sl-190\f1\fs20\cf0\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\b0\i0\ul0\strike0 Shared Hgb value: Y \f0\fs20\cf0\b0\i0\ul0\strike0 N\par\pard\plain\sl-284\par\pard\plain\li0\sl-190\f1\fs20\cf0\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\b0\i0\ul0\strike0 Weight

Gain pattern: \par\pard\plain\li393\sl-224\f0\fs20\cf0\b0\i0\ul0\strike0 01 \f0\fs20\cf0\b0\i0\ul0\strike0 02 05 22\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-351\par\pard\plain\li0\sl-190\f1\fs20\cf0\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\b0\i0\ul0\strike0 Health/medical: \par\pard\plain\li172\sl-224\f0\fs20\cf0\b0\i0\ul0\strike0 10 \f0\fs20\cf0\b0\i0\ul0\strike0 11 13 \f0\fs20\cf0\b0\i0\ul0\strike0 14 \f0\fs20\cf0\b0\i0\ul0\strike0 15 16 17 18 \f0\fs20\cf0\b0\i0\ul0\strike0 19 \par\pard\plain\li172\sl-230\f0\fs20\cf0\b0\i0\ul0\strike0 23 \f0\fs20\cf0\b0\i0\ul0\strike0 32 33 34 35 36 38 \f0\fs20\cf0\b0\i0\ul0\strike0 39 \f0\fs20\cf0\b0\i0\ul0\strike0 40 \par\pard\plain\li172\sl-230\f0\fs20\cf0\b0\i0\ul0\strike0 41 \f0\fs20\cf0\b0\i0\ul0\strike0 43 \f


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0\fs20\cf0\b0\i0\ul0\strike0 50 \f0\fs20\cf0\b0\i0\ul0\strike0 51 \f0\fs20\cf0\b0\i0\ul0\strike0 52 \f0\fs20\cf0\b0\i0\ul0\strike0 53 \f0\fs20\cf0\b0\i0\ul0\strike0 59 \f0\fs20\cf0\b0\i0\ul0\strike0 60 \f0\fs20\cf0\b0\i0\ul0\strike061 \par\pard\plain\li172\sl-230\f0\fs20\cf0\b0\i0\ul0\strike0 62\par\sect\sected\sbknone\cols2\colno1\colw4750\colsr10\colno2\colw7480\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Prenatal vitamin \par\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Multi vitamin \par\pard\plain\li1943\sl-230\f2\fs20\charscalex99\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\charscalex99\cf0\b0\i0\ul0\strike0Herbs or herbal remedies \par\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 None of these \par\pard\plain\li9\sl-230\column\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0Children\u8217?s\f0\fs20\cf0\b0\i0\ul0\strike0 vitamin \par\pard\plain\li23\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Iron \par\pard\plain\li0\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Medications:__________________ \par\pard\plain\li1324\sl-230\f0\fs20\cf0\b0\i0\ul0\strike0 __________________ \par\sect\sected\sbknone\cols2\colno1\colw8330\colsr10\colno2\colw3900\pard\plain\sl-271\par\pard\plain\li1583\sl-189\f0\fs20\cf0\b0\i0\ul0\strike0 What are your thoughts about breastfeeding? \par\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Good idea, I plan to exclusively breastfeed my baby \par\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Not sure, I would like more information \par\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 I plan to both breas

tfeed and formula feed my baby \par\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 I plan to feed my baby formula\par\pard\plain\sl-200\par\pard\plain\sl-297\par\pard\plain\li1583\sl-189\f0\fs20\cf0\b0\i0\ul0\strike0 Do you ever drink wine, beer or liquor? \par\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 No \par\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Yes \par\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 I would like to quit \par\pard\plain\sl-271\par\pard\plain\li1583\sl-189\f0\fs20\charscalex89\cf0\b0\i0\ul0\strike0 What was the date of your last alcoholic drink?_____________________ \par\pard\column\plain\sl-382\par\pard\plain\li57\sl-190\f1\fs20\cf0\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\b0\i0\ul0\strike0 Breastfeeding plan \par\pard\plain\li283\sl-224\f0\fs20\cf0\b0\i0\ul0\strike0 70 \par\pard\plain\sl-200\par\pard\plain\sl-200

\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-388\par\pard\plain\li0\sl-189\f0\fs20\cf0\b0\i0\ul0\strike0 Alcohol \par\pard\plain\li172\sl-230\f0\fs20\cf0\b0\i0\ul0\strike0 54\par\pard\plain\li115\sl-250\f1\fs20\cf0\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\b0\i0\ul0\strike0 3 months prior to pregnancy: \par\pard\plain\li336\sl-224\f0\fs20\cf0\b0\i0\ul0\strike0 _____days _____# drinks\par\pard\plain\sl-290\par\pard\plain\li115\sl-190\f1\fs20\cf0\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\b0\i0\ul0\strike0 Past month: \par\sect\sected\sbknone\cols1\colno1\colw12240\pard\plain\li8692\sl-224\f0\fs20\cf0\b0\i0\ul0\strike0 ____

_days _____# drinks \par\pard\plain\li1583\sl-326\f0\fs20\cf0\b0\i0\ul0\strike0 What best describes your smoking history? \par\sect\sected\sbknone\cols2\colno1\colw8330\colsr10\colno2\colw3900\pard\plain\li1943\sl-225\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Never smoked \par\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 S

moked, but I quit on _____________ (month and year) \par\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Currentlysmoke: ____________# cigarettes per day \par\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 I would like to quit \par\pard\plain\sl-271\par\pard\plain\li1583\sl-189\f0\fs20\cf0\b0\i0\ul0\strike0 Does anyone else living in your household smoke inside the home? \par\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 No \par\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Yes \par\pard\plain\sl-271\par\pard\plain\li1583\sl-189\f0\fs20\charscalex89\cf0\b0\i0\ul0\strike0 Since you have been pregnant, have y


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ou taken any other drug(s) such as \par\pard\plain\li1583\sl-230\f0\fs20\cf0\b0\i0\ul0\strike0 meth, crack, cocaine or marijuana? \par\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 No \par\pard\plain\li1943\sl-225\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Yes \par\pard\plain\li1943\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 I would like to quit \par\pard\plain\sl-271\par\pard\plain\li4094\sl-189\f0\fs20\cf0\b0\i0\ul0\strike0 Over please\u8230?\u8230?.\f0\fs20\cf0\b\i0\ul0\strike0 \par\pard\plain\sl-261\par\pard\plain\li1583\sl-171\f0\fs18\cf0\b0\i0\ul0\strike0 HNQ\u173?100 (1/08)\f0\fs18\cf0\b\i0\ul0\strike0 \par\pard\plain\li115\sl-364\column\f0\fs20\cf0\b0\i0\ul0\strike0 Smoking \par\pard\plain\li225\sl-230\f0\fs20\cf0\b0\i0\ul0\strike0 55 63\par\pard\plain\li115\sl-246\f1\fs20\cf0\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\b0\i0\ul0\strike03 months prior to pregnancy: \par\pard\plain\li283\sl-229\f0\fs20\cf0\b0\i0\ul0\strike0 _____ # cigs per day \par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-327\par\pard\plain\li0\sl-189\f0\fs20\cf0\b0\i0\ul0\strike0 Family environment: \par\pard\plain\li225\sl-230\f0\fs20\cf0\b0\i0\ul0\strike0 90 96 97 \par\pard\plain\sl-200\par\pard\plain\sl-302\par\pard\plain\li172\sl-189\f0\fs20\cf0\b0\i0\ul0\strike0 56{\shp{\*\shpinst\shpleft0\shptop0\shpright12300\shpbottom15940\shpfhdr0\shpbxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz2102\shplid15105{\sp{\sn shapeType}{\sv 1}}{\sp{\sn lTxid}{\sv 19401}}{\sp{\sn fFilled}{\sv 0}}

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8/31

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9/31

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10/31

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11/31

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12/31

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13/31

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


14/31

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

045454be4bfac5ff007fe0ff00e394792feb17fdff0083ff008e50045454be4bfac5ff007fe0ff00e394792feb17fdff0083ff008e50045454be4bfac5ff007fe0ff00e394792feb17fdff0083ff008e50045454be4bfac5ff007fe0ff00e394792feb17fdff0083ff008e500455e13fb437fc8a5f0ebfecea3f625ffd6c9f8115ef4626009263c004f13424f1e803924fa00093d00cd782fed0dff2297c3aff00b3a8fd897ff5b27e045007e9f514514005145140051451400514514005145140051451400514514005145140051451400514514005145140051451400514514005145140051451400514514005145140051451400514514005145140051451400514514005145140051451400514514005145140051451400514514005145140051451400514514005145140051451400514514005145140051451401f30fed67ff24e7c29ff0065b3e07ffeacdf0e572b5d57ed67ff0024e7c29ff65b3e07ff00eacdf0e572b400514514005145140051451400514514005145140051451400514514005145140051451400514514005145140051451400514514005784fed0dff2297c3aff00b3a8fd897ff5b27e0457bb5784fed0dff2297c3aff00b3a8fd897ff5b27e045007e9f514514005145140051451400514514005145140051451400514514005145140051451400514514005145140051451400514514005145140051451400514

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


15/31

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

1450014514500145145001451450014514500145145001451450014514500145145001451450015e13fb437fc8a5f0ebfecea3f625ff00d6c9f8115eed5e13fb437fc8a5f0ebfecea3f625ff00d6c9f811401fa7d451450014514500145145001451450014514500145145001451450014514500145145001451450014514500145145001451450014514500145145001451450014514500145145001451450014514500145145001451450014514500145145001451450014514500145145001451450014514500145145001451450014514500145145001451450014514500145145007cc3fb59ff00c939f0a7fd96cf81ff00fab37c395cad755fb59ffc939f0a7fd96cf81fff00ab37c395cad001451450014514500145145001451450014514500145145001451450014514500145145001451450014514500145145001451450015e13fb437fc8a5f0ebfecea3f625ff00d6c9f8115eed5e13fb437fc8a5f0ebfecea3f625ff00d6c9f811401fa7d4514500145145001451450014514500145145001451450014514500145145001451450014514500145145001451450014514500145145001451450014514500145145001451450014514500145145001451450014514500145145001451450014514500145145001451450014514500145145001451450014514500145145001451450014514500145145001451450079cfc54f851e0a

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}{\par}\pard \ql \li0\ri0\nowidctlpar\faauto\rin0\lin0\itap0 {\par}}}}}}\sect\sectd\sbkpage\pgwsxn12240\pghsxn15840\sected\cols2\colno1\colw7610\colsr


16/31

10\colno2\colw4620\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-221\par\pard\plain\li758\sl-189\f0\fs20\cf0\b0\i0\ul0\strike0 Have you seen your dentist yet during this pregnancy? \par\pard\plain\li1224\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 No \par\pard\plain\li1224\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Yes \par\pard\plain\li1224\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 I would like to find a dentist \par\pard\plain\sl-271\par\pard\plain\li864\sl-189\f0\fs20\cf0\b0\i0\ul0\strike0 Do you have a cavity to be filledor tooth to be pulled? \par\pard\plain\li1224\sl-225\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 No \par\pard\plain\li1224\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Yes \par\pard\plain\sl-271\par\pard\plain\li864\sl-189\f0\fs20\cf0\b0\i0\ul0\strike0 Check any ofthe following that you are experiencing: \par\pard\column\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-216\par\pard\plain\li940\sl-189\f0\fs20\cf0\b\i0\ul0\strike0 Staff use only:\par\pard\plain\li0\sl-255\f1\fs20\cf0\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\b0\i0\ul0\strike0 Nutrition practices: \par\pard\plain\li393\sl-224\f0\fs20\cf0\b0\i0\ul0\strike0 42 \f0\fs20\cf0\b0\i0\ul0\strike0 6566 88\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-238\par\pard\plain\li0\sl-190\f1\fs20\cf0\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\b0\i0\ul0\strike0 Topics discussed:\par\sect\sected\sbknone\cols3\colno1\colw4210\colsr10\colno2\colw3390\colsr10\colno3\colw4620\pard\plain\li868\sl-301\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Feeling sick to mystomach \par\pard\plain\li868\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs2

0\cf0\b0\i0\ul0\strike0 Constipation \par\pard\plain\li868\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Throwing up \par\pard\plain\li868\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Heartburn \par\pard\plain\li868\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 No appetite \par\pard\plain\li868\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 None of the above\f0\fs20\cf0\b\i0\ul0\strike0 \par\pard\plain\li0\sl-301\column\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Diarrhea \par\pard\plain\li0\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Eating all the time! \par\pard\plain\li0\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Food cravings \par\pard\plain\li0\sl-230\f2\fs20\charscalex89\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\charscalex89\cf0\b0\i0\ul0\strike0 Cravings for things like ice, baking \par\pard\plain\li283\sl-230\f0\fs20\c

f0\b0\i0\ul0\strike0 soda, clay, or cornstarch \par\pard\column\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-236\par\pard\plain\li0\sl-190\f1\fs20\cf0\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\b0\i0\ul0\strike0 Ed materials given: \par\sect\sected\sbknone\cols2\colno1\colw7670\colsr10\colno2\colw4560\pard\plain\li864\sl-286\f0\fs20\charscalex96\cf0\b0\i0\ul0\strike0 Are you following a prescribed special diet, weight control diet, vegan or \par\pard\plain\li864\sl-230\f0\fs20\cf0\b0\i0\ul0\strike0 macrobiotic way of eating? \par\pard\plain\li1224\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0No \par\pard\plain\li1224\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Yes: please \par\pard\plain\li1224\sl-225\f0\fs20\cf0\b0\i0\ul0\strike0 describe:_____________________________________ \par\pard\plain\sl-271\par\pard\plain\li864\sl-189\f0\fs20\cf0\b0\i0\ul0\strike0 How many times a da

y do you usually eat? ______ # meals per day \par\pard\plain\li4756\sl-230\f0\fs20\cf0\b0\i0\ul0\strike0 ______ # snacks per day \par\pard\plain\li0\sl-224\column\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 None \par\pard\plain\li0\sl-230\f2\fs20\cf0\chcbpat1\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\chcbpat1\b0\i0\ul0\strike0 Guide to Healthy Baby \f0\fs18\cf0\chcbpat1\b0\i0\ul0\strike0 (Spangler) \par\pard\plain\li0\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0\u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Loving Support material \par\pard\plain\li0\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 After You Deliver \par\pard\plain\li0\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Deliver a Healthy Smile \par\pard\plain\li0\sl-225


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\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Other:\par\sect\sected\sbknone\cols3\colno1\colw6310\colsr10\colno2\colw1290\colsr10\colno3\colw4620\pard\plain\sl-263\par\pard\plain\li864\sl-197\f0\fs20\charscalex89\cf0\b0\i0\ul0\strike0 How would you describe your appetite? \f2\fs20\charscalex89\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\charscalex89\cf0\b0\i0\ul0\strike0 Good \f2\fs20\charscalex89\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\charscalex89\cf0\b0\i0\ul0\strike0 Fair \par\pard\column\plain\sl-263\par\pard\plain\li0\sl-197\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Poor \par\pard\column\plain\sl-228\par\pard\plain\li0\sl-190\f1\fs20\cf0\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\b0\i0\ul0\strike0 Referrals: \par\pard\plain\li115\sl-224\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 None \par\sect\sected\sbknone\cols2\colno1\colw7610\colsr10\colno2\colw4620\pard\plain\li864\sl-278\f0\fs20\cf0\b0\i0\ul0\strike0 Do you ever drink raw or bulk tank milk or un\u173?pasteurized juice? \par\pard\plain\li1224\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0\u168?\f0\fs20\cf0\b0\i0\ul0\strike0 No \par\pard\plain\li1224\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Yes \par\pard\plain\sl-271\par\pard\plain\li864\sl-189\f0\fs20\cf0\b0\i0\ul0\strike0 Do you eat fishmore than 2 times a week? \par\pard\plain\li1224\sl-225\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 No \par\pard\plain\li1224\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Yes \par\pard\plain\sl-271\par\pard\plain\li864\sl-189\f0\fs20\cf0\b0\i0\ul0\strike0 Do you eat soft cheeses such as Brie, feta or Camembert? \par\pard\plain\li1224\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 No \par\pard\plain\li1224\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\str

ike0 Yes \par\pard\plain\sl-271\par\pard\plain\li864\sl-189\f0\fs20\charscalex96\cf0\b0\i0\ul0\strike0 Which group of foods below do you find most challengingto eat enough \par\pard\plain\li864\sl-230\f0\fs20\cf0\b0\i0\ul0\strike0 of? \par\pard\plain\li1257\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 \f0\fs20\cf0\b0\i0\ul0\strike0 Milk, yogurt, cheese \par\pard\plain\li1257\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 \f0\fs20\cf0\b0\i0\ul0\strike0 Protein foods like: meat, fish, eggs, beans \par\pard\plain\li1257\sl-225\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 \f0\fs20\cf0\b0\i0\ul0\strike0 Fruits \par\pard\plain\li1257\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 \f0\fs20\cf0\b0\i0\ul0\strike0 Vegetables \par\pard\plain\li1257\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 \f0\fs20\cf0\b0\i0\ul0\strike0 Bread, cereal, rice, pasta \par\pard\plain\li1257\sl-230\f2\fs20\cf0\b

0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 \f0\fs20\cf0\b0\i0\ul0\strike0 Other: ___________________________ \par\pard\plain\sl-271\par\pard\plain\li864\sl-189\f0\fs20\cf0\b0\i0\ul0\strike0 How would you describe your daily activity? (check one) \par\pard\plain\li1224\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 very active (run, aerobics, chopping wood)\par\pard\plain\li1224\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 moderately active (brisk walking, biking, hiking) \par\pard\plain\li1224\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 somewhat active (easy walking, light housework) \par\pard\plain\li1224\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 not active (sit most of the day) \par\pard\plain\li115\sl-230\column\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 HBKF\u8230?\u8230?.\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Declined \par\pard\plai

n\li115\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Provider/medical home \par\pard\plain\li115\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 _________________\par\pard\plain\sl-290\par\pard\plain\li0\sl-190\f1\fs20\cf0\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\b0\i0\ul0\strike0 SMART plan is:\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-353\par\pard\plain\li0\sl-190\f1\fs20\cf0\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\b0\i0\ul0\strike0 Nutrition follow up/next steps: \par\pard\plain\li57\sl-224\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i


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0\ul0\strike0 INCP \par\pard\plain\li57\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 28 week recall \par\pard\plain\li57\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Phone call \par\pard\plain\li57\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Weight check \par\pard\plain\li57\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Clinic or office visit \par\pard\plain\li57\sl-230\f2\fs20\cf0\chcbpat1\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\chcbpat1\b0\i0\ul0\strike0 Invited to group/nutrition activity: \par\pard\plain\sl-258\par\pard\plain\li57\sl-197\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Other:\par\pard\plain\sl-290\par\pard\plain\li0\sl-190\f1\fs20\cf0\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\b0\i0\ul0\strike0 Food package: AF \par\sect\sected\sbknone\cols1\colno1\colw12240\pard\plain\li7862\sl-224\f0\

fs20\cf0\b0\i0\ul0\strike0 Omissions: \par\pard\plain\sl-271\par\pard\plain\li864\sl-189\f0\fs20\cf0\b0\i0\ul0\strike0 I would like to learn more about\u8230?\u8230?.. \par\sect\sected\sbknone\cols3\colno1\colw4190\colsr10\colno2\colw3410\colsr10\colno3\colw4620\pard\plain\li974\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Healthy snacks for pregnancy \par\pard\plain\li974\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0Breastfeeding my baby \par\pard\plain\li0\sl-230\column\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Oral health for pregnancy \par\pard\plain\li0\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Food resources in my area \par\pard\plain\li0\sl-230\column\f0\fs20\cf0\chcbpat1\b0\i0\ul0\strike0 _____________________________\par\pard\plain\li57\sl-250\f1\fs20\cf0\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\b0\i0\ul0\strike0 Staff sign

ature & title \par\sect\sected\sbknone\cols2\colno1\colw7610\colsr10\colno2\colw4620\pard\plain\li974\sl-209\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Ways to stretch my food dollars \f2\fs20\cf0\b0\i0\ul0\strike0\u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Other: \par\pard\plain\li974\sl-230\f2\fs20\cf0\b0\i0\ul0\strike0 \u168?\f0\fs20\cf0\b0\i0\ul0\strike0 Breastpumps fromWIC \par\pard\plain\sl-200\par\pard\plain\sl-200\par\pard\plain\sl-260\par\pard\plain\li4847\sl-171\f0\fs18\cf0\b0\i0\ul0\strike0 Vermont WIC Program \par\pard\plain\li0\sl-224\column\f0\fs20\cf0\chcbpat1\b0\i0\ul0\strike0 _________________

____________\par\pard\plain\li0\sl-250\f1\fs20\cf0\b0\i0\ul0\strike0 \u167?\f0\fs20\cf0\b0\i0\ul0\strike0 Date of visit{\shp{\*\shpinst\shpleft0\shptop0\shpright12300\shpbottom15940\shpfhdr0\shpbxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz2095\shplid15105

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19/31

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