AFS WIC Application1Family Information2Pregnant Woman Application3Breastfeeding/Postpartum Women Application4Infant Application5Infant Application6Child Application7Child Application8Child Application1. Are you currently on WIC? Yes No1A. Where?2. Have you been on WIC before? Yes No2A. Where?3. How did you hear about WIC?DKC/MedicaidFriend/Family MemberHead Start/SchoolHealth Care ProviderMedia4. Your Name(Required) First Middle Last 5. Maiden Name6. Date of Birth(Required)7. Physical Address(Required)8. Apartment or Suite Number (Optional)9. City(Required)10. State(Required)11. ZIP Code(Required)Is your mailing address the same as your physical?(Required) Yes No12. Mailing Address(Required)13. Apartment or suit number (Optional)14. City(Required)15. State(Required)16. ZIP(Required)17. Cell Phone(Required)18. Home Phone19. Other Phone20. Email Address(Required)21. Are you Hispanic or Latino?(Required) Yes No22. Race (Check all that apply)(Required) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White23. Are you applying for your own WIC benefits today? Yes No24. Are you currently working?(Required) Yes No24A. Hourly/Salary Amount(Required)24B. Hours per week/pay period(Required)25. Is anyone else in your household working?(Required) Yes No25A. Hourly/Salary Amount(Required)25B. Hours per week/pay period(Required)26. How many people live in your home?(Required)27. Are you pregnant?(Required) Yes No28. Would you like us to consider your unborn child as a member of your household? (financial eligibility may be determined by income and household size) Yes No29. How many people in your household received the most recent PFD?(Required)Include even if garnished.30. Check any of the following programs you or any family member is currently receiving: Food Stamps/SNAP Medicaid/Denali Kid Care Alaska Temporary Assistance Program (ATAP) Applied for Denali Kid Care, Medicaid, ATAP - Application Pending31. Check if any other money received by you or anyone in your household (include monthly amount) Supplemental Security Income/Disability Self Employment Unemployment Native Corporation Dividends Commissions OtherMonthly SSI/Disability Received:(Required)Monthly Self Employment Received:(Required)Monthly Unemployment Received:(Required)Annual Native Corporation Dividends:(Required)Monthly Commissions Received:(Required)Other Monthly Income:(Required)32. Marital Status(Required) Married Single Divorced Separated Living with Partner/Significant Other Widowed33. Highest Education Level Completed(Required)12th Grade or GED11th Grade10th Grade9th Grade8th Grade7th Grade6th Grade1 Year or Less of College2 Years of College3 Years of College4 or 5 Years of College1 Year of Grad School2 or More years of Grad School34. Would you like to register to vote? (U.S. Citizens only)(Required) Already Registered Yes NoRights & Responsibilities(Required) I have read & agree.Alaska WIC Rights and Responsibilities You have rights and responsibilities as a WIC participant. The names and addresses of you and your child may be given to agencies such as Medicaid, Denali Kid Care, Supplemental Nutrition Assistance Program (SNAP), Heating Assistance, Temporary Assistance, Child Care, Infant Learning, Head Start and Public Health Nursing Programs for referral and outreach. Programs listed above may give the WIC program name(s), address, income, identification and residency for you and your child to help check if you qualify for WIC. Other WIC information may also be shared with health programs to see if you qualify for their program’s services, to share needed health information with programs you are already participating in, and to help assess the overall health of Alaskan families through reports and studies. These same programs listed below may also share their information with WIC for the same purposes. You may ask WIC staff for more information about these programs. These programs include: Medicaid, Denali Kid Care, Pro Care, Head Start, Supplemental Nutrition Assistance Program (Formally known as the Food Stamp Program), Immunizations Program, Public Health Nursing, State Epidemiology and Infant Learning Program. I understand my Rights and Responsibilities Responsibilities: • I will treat WIC and store staff with courtesy and respect. • All the information I give WIC is true and accurate. WIC staff can check this information. • I will immediately report any changes in my income, family size, address, phone number or eligibility for Medicaid/Denali Kid Care, or the SNAP Program. I will also notify the WIC office if my card is lost or stolen, or if I am no longer breastfeeding. • I will get WIC benefits from only one clinic at a time. If I move out of Alaska, I will ask for a transfer. • I will not sell, or try to sell my eWIC card, trade or give away formula or other WIC food benefits and breast pumps. This includes sell of such items in person, in print, or online. • I will be removed from the WIC program if my benefits are not issued or I do not use my benefits, for two months in a row. • I will allow WIC staff to take my or my child’s height and weight and take a small amount of blood to check my or my child’s iron level. I understand this information is needed to check nutrition needs and determine eligibility for WIC. • I will come to my appointments or call ahead when I need to reschedule. • I will reapply for benefits as needed. I understand that WIC benefits are for participant use only. • I will follow the WIC program and shopping rules that are on my WIC food list. • WIC is a Federal program. If I break the rules, make false statements, intentionally misrepresent, conceal, or withhold facts about my eligibility for the WIC Program, I understand that: • I or my child can be taken off WIC. • I will have to pay money back to WIC for foods, formula or breast pumps I should not have received. If I do not pay back the WIC program for foods and/or formula that I accepted or return loaned breast pumps that I was not eligible to receive, the state may use other types of legal options to collect payment, including small claims court, which could result in Permanent Fund Dividend (PFD) garnishment. • I can face civil or criminal prosecution under State and Federal law. Rights: • If I qualify for WIC, I will get benefits to buy healthy foods. I understand that WIC does not give all the food or formula needed in a month. WIC foods help promote and support the nutrition and well-being and help meet the needed intake of important nutrients or foods for myself and / or my child(ren). • WIC will give me information for healthy eating and active living. WIC will provide me with breastfeeding support. • WIC will give me information to find a doctor and get immunizations for my child. I will be referred to other services. • WIC staff will treat me with courtesy and respect. • WIC will keep information about me and / or my child(ren) confidential and share only needed information to determine eligibility and for referral to other services. • The rules for getting on WIC are the same for everyone. I can ask for a Fair Hearing if I do not agree with a decision about my WIC eligibility. WIC will tell me why my child or I qualify for the WIC Program. By signing this form I agree that: • I have read the Rights and Responsibilities form or a WIC staff has read it to me. • I agree to the above.Initial & Date(Required)Additional Info35. Does anyone smoke cigarettes, pipes, or cigars anywhere inside your home?(Required) Yes No36. Does your family stay in a shelter, temporary home, or in a place not usually used for sleeping?(Required) Yes No37. Do you have a refrigerator, a stove that works, and storage free from pests and harmful chemicals?(Required) Yes No38. Did a family member have a seasonal farming job with a temporary home in the last 24 months?(Required) Yes No39. What type of milk would you like on your food package?(Required) Fresh/Refrigerated Boxed (UHT) Soy Dry Evaporated Lactose Reduced40. What concerns, if any, do you have about having enough food to feed your family?(Required)41. What does your family do for fun?(Required)Who are you applying for? (Check all that apply)(Required) New Pregnancy Miscarriage New Baby (under the age of 1) Child (between ages 1 and 4)Did you give birth to the baby(s) you're applying for?(Required) Yes NoCAPTCHAP3. Due Date(Required) MM slash DD slash YYYY P4. Medicaid number (if receiving)P7. How is your pregnancy going? Please tell us if you have any concerns.P8. The date I started seeing a doctor for this pregnancy:P8. A. Check this box if: I have not started seeing a doctor for this pregnancy.P9. When was your last pregnancy?Month, YearP10. How many babies are you expecting?P11. How many times have you been pregnant?Do not count this pregnancy.P12. How old are your children?P13. How much did you weigh before this pregnancy?P14. Are you breastfeeding another child? Yes NoP15. Check any problems you had with any of your pregnancies: Never been pregnant before or didn't have problems. Miscarried Stillbirth Abortion Baby born 3 or more weeks early Baby, less than 5lbs 9oz at birth Baby, 9lbs or more at birth Baby died before 1 month old Genetic or birth defects C-section History of Gestational Diabetes History of PreeclampsiaP15. A. Number of MiscarriagesP15. B. Number of StillbirthsP15. C. Number of AbortionsP16. Check if you are having any of the following problems with this pregnancy: Constipation Heartburn Nausea VomitingP17. Did you take vitamins before your pregnancy? Yes NoP17. A. How often?P18. List any medication, vitamin, prenatal vitamins, mineral, or herbal supplement you are taking. If not daily, how often?P19. Please, tell us if you see a doctor, dietitian, or health care porvider for medical or emotional reasonsex: fetal growth restriction, hypertension, prehypertension, gestational diabetes, diabetes, anemia, or gastrointestinal disorders.P20. If you were in the hospital in the last 3 months, please tell us why.P21. Do you smoke cigarettes, pipes, or cigars? Yes NoP21. A. Amount per day?P22. Did you smoke before your pregnancy? Yes NoP22. A. Amount per day?P23. Did you smoke cigarettes, pipes, or cigars at any time during this pregnancy? Yes NoP25. Do you use smokeless, chewing tobacco, or iqmik? Yes NoP25. A. Amount per day?P26. Did you drink alcohol before your pregnancy? Yes NoP26. A. Amount per week?P27. Did you drink wine, beer, or other alcoholic beverages during this pregnancy? Yes NoP27. A. Amount per day?P27. B. Amount per week?P28. Check any drugs you are using during this pregnancy: None Cocaine Crank Crack Methamphetamine Heroin Marijuana Methadone Speed Other Stopped UsingP28. A. What other drug(s) are/were you using?P28. B. When did you stop using?P30. How do you plan to feed your baby? Breastmilk Breastmilk/Formula Formula UnsureP30. A. Have you breastfed before? Yes NoP31. On a scale of 0 to 10, How ready do you feel about breastfeeding your baby? 0 Not Ready 1 2 3 4 5 6 7 8 9 10 ReadyP32. On a scale of 0 to 10, How well do you think you are eating? 0 Not Well 1 2 3 4 5 6 7 8 9 10 Very WellP32. A. How many meals do you eat per day?P32. B. How many snacks do you eat per day?P32. C. How many cups of fruit do you eat per day? 1 cup or less per day 2 cups per day 3 cups or more per dayP32. D. How many cups of vegetables do you eat per day? 1 cup or less per day 2 cups per day 3 cups or more per dayP33. Check if you are eating any of these foods: Raw Sprouts: Alfalfa, clover, and radish Raw or Undercooked: meat, chicken, turkey, fish, eggs Uncooked refrigerated smoked seafood Unheated Meats: lunch meats, deli-style meat or chicken, fermented and dry sausage, raw hot dogs Food with raw or undercooked eggs: salad dressing, cookie and cake batter, sauces Soft cheese made with unpasteurized milk: feta, mexican-style (queso blanco fresco), brie, blue Unpasteurized milk or foods made with unpasteurized milk Unpasteurized fruit or vegetable juiceP34. Check if you crave or eat any of the following: Ashes Baking Soda Burnt Matches Carpet Fibers Chalk Cigarettes Clay Dust Paint Chips Soil Starch (laundry or cornstarch) Large quantities of ice and/or freezer frostP35. Do you fast, binge, or vomit to control your weight or follow a specific diet? Yes NoP35. A. Please describe:P36. Do you have any problems eating any type of food for any reason such as dental problems, food intolerances, food allergies, or others?P37. Have you been screened or referred for lead poisoning? Yes NoP38. Are you in a relationship with anyone who pushes, hits, or threatens you in any way? Yes NoP39. How often do you feel down, depressed, or hopeless? Never Sometimes Often AlwaysP40. What problems, if any, do you have caring for yourself?P41. When was your last dental check-up?Month, YearPP3. Medicaid number (if receiving)PP6. How are you doing after having your baby? Please tell us if you have any concerns.PP10. How many weeks did your pregnancy last?PP11. When did your prenatal care begin?Month, YearPP12. How many babies did you have during your last pregnancy?PP13. How many times have you been pregnant?Do not count this pregnancy.PP13. How far apart were your last 2 pregnancies?PP15. How old are your children?PP16. How much did you weigh before pregnancy?PP17. Check if you had any of the problems during your recent pregnancy: Miscarried Stillbirth More than 1 baby Baby born 3 or more weeks early Baby, less than 5lbs 9oz at birth Baby, 9lbs or more at birth Baby died before 1 month old Genetic or birth defects C-section History of Gestational Diabetes History of PreeclampsiaPP17. A. Number of MiscarriagesPP17. B. Number of StillbirthsPP17. C. Number of babies bornPP18. List any medication, vitamin, prenatal vitamins, mineral, or herbal supplement you are taking. If not daily, how often?PP19. Please, tell us if you see a doctor, dietitian, or health care provider for medical or emotional reasons.ex: hypertension, pre-hypertension, pre-diabetes, diabetes, anemia, or gastrointestinal disorders.PP20. If you were in the hospital in the last 3 months, please tell us why.PP21. Do you smoke cigarettes, pipes, or cigars? Yes NoPP21. A. How many per day?PP22. Did you smoke in the last 3 months of your pregnancy? Yes NoPP22. A. How many per day?PP24. Do you use smokeless, chewing tobacco, or iqmik? Yes NoPP24. A. How many per day?PP25. Did you drink alcohol in the last 3 months of your pregnancy? Yes NoPP25. A. How many per week?PP26. Do you drink wine, beer, or other alcoholic beverages? Yes NoPP26. A. How many per day?PP26. B. How many per week?PP27. Check any drugs you are using during this pregnancy: None Cocaine Crank Crack Methamphetamine Heroin Marijuana Methadone Speed Other Stopped UsingPP27. A. What other drugs?PP27. B. When did you stop?PP29. How are you feeding your baby?(Required) Breastmilk Breastmilk/Formula Formula OnlyPP30. Did you ever breastfeed? Yes NoPP31. Date Breastfeeding began:PP31. A. When did breastfeeding end?PP31. B. When did you introduce formula?PP31. C. What was the reason that breastfeeding was stopped?PP31. D. How long did you breastfeed?days/weeksPP32. On a scale of 0 to 10, how confident are you about breastfeeding your baby? 0 Not Confident 1 2 3 4 5 6 7 8 9 10 Very ConfidentPP32. A. How long do you plan to breastfeed?PP35. On a scale of 0 to 10, how well do you think you are eating? 0 Not Well 1 2 3 4 5 6 7 8 9 10 Very WellPP35. A. How many meals do you eat per day?PP35. B. How many Snacks do you eat per day?PP35. C. How many cups of fruit do you eat per day? 1 cup or less per day 2 cups per day 3 cups or more per dayPP35. D. How many cups of vegetables do you eat per day? 1 cup or less per day 2 cups per day 3 cups or more per dayPP36. Check if you crave or eat any of the following: Ashes Baking Soda Burnt Matches Carpet Fibers Chalk Cigarettes Clay Dust Paint Chips Soil Starch (laundry or cornstarch) Large quantities of ice and/or freezer frostPP37. Do you fast, binge, vomit to control your weight or follow a specific diet? Yes NoPP37. A. Please describePP38. Do you have any problems eating any type of food for any reason such as dental problems, food intolerances, food allergies, or others?PP39. Have you been screened or referred for lead poisoning? Yes NoPP43. Are you in a relationship with anyone who pushes, hits, or threatens you in any way? Yes NoPP44. How often do you feel down, depressed, or hopeless? Never Sometimes Often AlwaysPP46. What problems, if any, do you have caring for yourself?PP47. When was your last dental check-up?Month, YearB1. Baby's Name (First, Middle, Last)(Required)B2. Baby's Birth Date(Required)B3. Baby's Gender:(Required) Boy GirlB4. What is your relationship to Baby?B5. Baby's Denali Kid Care #If applicableB6. Is Baby Hispanic or Latino?(Required) Yes NoB7. Baby's Race (Check all that apply)(Required) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander WhiteB8. What concerns, if any, do you have about what, how, or how much your baby eats?B9. A. Baby's Birth Weight:B9. B. Baby's Birth Length:B10. What birthing facility was Baby born at?B11. Are you breastfeeding another child? Yes NoB12. Are Baby's immunizations up to date? Yes NoB13. Please list any medications your baby may be taking:B14. Please tell us if your baby sees a doctor, dietician, or health care provider for medical reasons:ex: hypertension, prehypertension, diabetes, fetal alcohol syndrome, small for gestational age, gastrointestinal disorders, or anemia.B15. If your baby was in the hospital in the last 3 months, please tell us why.Other than birthB20. On a scale of 0 to 10, how well do you feel breastfeeding is going for your baby? 0 Not Well 1 2 3 4 5 6 7 8 9 10 Very WellB20.A. How many times a day does baby breastfeed?B20.B. How many minutes do feedings last?B20.C. How many times a day does your baby poop?B20.D. How many wet diapers does your baby have per day?B21. How do you store breastmilk?i.e. freeze, refrigerate, store on counter, in cabinet, etc.B22. What do you usually do, if there is leftover breastmilk or formula in the bottle after feeding? Throw it out Refrigerate it Leave near babyB23. What formula are you feeding your baby?B24. On a scale of 0 - 10, how well do you think formula feeding is going? 0 Not Well 1 2 3 4 5 6 7 8 9 10 Very WellB25. How often do you feed your baby formula?B26. How much formula does your baby eat at feeding?B27. How do you prepare your baby's formula? Powdered Formula Concentrated Formula Ready to feed formulaB27.A. Number of scoops of powderB27.B. Ounces of waterB27.C. Ounces of formulaB27.D. Ounces of waterB27.E. Do you add water? Yes NoB27.F. How many ounces?B28. Does your baby drink juice, sweetened drinks, soda, sweet tea, Tang/Koolaid or Hi-C in a bottle or cup? Yes No SometimesB29. Do you add sugar, honey, or syrup to your baby's pacifier or foods? Yes No SometimesB29.A. Please tell us more about the reasons:B30. How old was your baby the first time he/she drank liquids other than breastmilk or formula? List what he/she drank:B31. How old was your baby the first time he/she ate food such as cereal, baby food, or any other food? List what he/she ate:B32. Is your baby held when bottle fed? Never Rarely Sometimes AlwaysB33. Where else do you give your baby a bottle? Crib/Bed Car Seat High Chair Stroller OtherB33.A. Please describeB34. How do you feed your baby solid food? No solid foods, only breastmilk/formula By Spoon In a Baby Bottle By Infant Feeder Baby Foods Finger Foods OtherB34.A. Please describeB35. Check all that apply if your baby is eating any of these foods. No solid foods, only breastmilk/formula Raw Sprouts: alfalfa, clover, and radish Raw or undercooked: meat, chicken, turkey, fish, eggs Uncooked refrigerated smoked seafood Unheated meats: lunch meats, deli-style meat or chicken, fermented and dry sausage, raw hot dogs Strained: meat, egg yolk, yogurt, cottage cheese, tuna Strained or mashed: vegetables or fruits Chopped: fruits or vegetables Homemade baby food bread Food with raw or undercooked eggs: salad dressing, cookie and cake batter, sauces Soft cheese made with unpasteurized milk: feta, mexican-style (queso blanco fresco), brie, blue Unpasteurized milk or foods made with unpasteurized milk Unpasteurized fruit or vegetable juice Cooked soft pieces of beans, chicken, turkey, beef, pork Infant Cereal in the bottle Infant Cereal crackersB36. How do you know your baby is done eating? Check all that apply Turns head away Won't open his/her mouth Eats all food Bottle is empty Spits out foodB37. Please describe any teething problems your baby may be having:B38. Please describe any food intolerances or food allergies your baby may have:B39. Has your baby been screened or referred for lead poisoning? Yes NoB44. Do you have any concerns about anyone hurting your baby? Yes NoB45. Has your child been in foster care or moved to a new foster home within the last 6 months? Yes NoB46. Do you have any problems taking care of your baby?B47.A. Please list Dad's Weight:B47.B. Please list Dad's Height:Do you need to add a 2nd Baby? Yes NoBB1. Baby's Name (First, Middle, Last)(Required)BB2. Baby's Birth Date(Required)BB3. Baby's Gender:(Required) Boy GirlBB4. What is your relationship to Baby?BB5. Baby's Denali Kid Care #If applicableBB6. Is Baby Hispanic or Latino?(Required) Yes NoBB7. Baby's Race (Check all that apply)(Required) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander WhiteBB8. What concerns, if any, do you have about what, how, or how much your baby eats?BB9.A. Baby's Birth Weight:BB9.B. Baby's Birth Length:BB10.A. What birthing facility was Baby born at?BB10.B. How many weeks did your pregnancy last?BB12. Are Baby's immunizations up to date? Yes NoBB13. Please list any medications your baby may be taking:BB14. Please tell us if your baby sees a doctor, dietician, or health care provider for medical reasons:ex: hypertension, prehypertension, diabetes, fetal alcohol syndrome, small for gestational age, gastrointestinal disorders, or anemia.BB15. If your baby was in the hospital in the last 3 months, please tell us why.BB16. How are you feeding your baby?(Required) Breastmilk Breastmilk/Formula Formula OnlyBB16. A. Did you ever breastfeed? Yes NoBB17. A. When did breastfeeding begin?BB17. B. When did breastfeeding end?BB17. C. What was the reason breastfeeding stopped?BB20. On a scale of 0 to 10, how well do you feel breastfeeding is going for your baby? 0 Not Well 1 2 3 4 5 6 7 8 9 10 Very WellBB20.A. How many times a day does baby breastfeed?BB20.B. How many minutes do feedings last?BB20.C. How many times a day does your baby poop?BB20.D. How many wet diapers does your baby have per day?BB23. A. What age did you start your baby on formula?BB23. B. What formula are you feeding your baby?BB24. On a scale of 0 - 10, how well do you think formula feeding is going? 0 Not Well 1 2 3 4 5 6 7 8 9 10 Very WellBB25. How often do you feed your baby formula?BB26. How much formula does your baby eat at feeding?BB27. How do you prepare your baby's formula? Powdered Formula Concentrated Formula Ready to feed formulaBB27.A. Number of scoops of powderBB27.B. Ounces of waterBB27.C. Ounces of formulaBB27.D. Ounces of waterBB27.E. Do you add water? Yes NoBB27.F. How many ounces?BB28. Does your baby drink juice, sweetened drinks, soda, sweet tea, Tang/Koolaid or Hi-C in a bottle or cup? Yes No SometimesBB29. Do you add sugar, honey, or syrup to your baby's pacifier or foods? Yes No SometimesBB29.A. Please tell us more about the reasons:BB30. How old was your baby the first time he/she drank liquids other than breastmilk or formula? List what he/she drank:BB31. How old was your baby the first time he/she ate food such as cereal, baby food, or any other food? List what he/she ate:BB32. Is your baby held when bottle fed? Never Rarely Sometimes AlwaysBB33. Where else do you give your baby a bottle? Crib/Bed Car Seat High Chair Stroller OtherBB33.A. Please describeBB34. How do you feed your baby solid food? No solid foods, only breastmilk/formula By Spoon In a Baby Bottle By Infant Feeder Baby Foods Finger Foods OtherBB34.A. Please describeBB35. Check all that apply if your baby is eating any of these foods. No solid foods, only breastmilk/formula Raw Sprouts: alfalfa, clover, and radish Raw or undercooked: meat, chicken, turkey, fish, eggs Uncooked refrigerated smoked seafood Unheated meats: lunch meats, deli-style meat or chicken, fermented and dry sausage, raw hot dogs Strained: meat, egg yolk, yogurt, cottage cheese, tuna Strained or mashed: vegetables or fruits Chopped: fruits or vegetables Homemade baby food bread Food with raw or undercooked eggs: salad dressing, cookie and cake batter, sauces Soft cheese made with unpasteurized milk: feta, mexican-style (queso blanco fresco), brie, blue Unpasteurized milk or foods made with unpasteurized milk Unpasteurized fruit or vegetable juice Cooked soft pieces of beans, chicken, turkey, beef, pork Infant Cereal in the bottle Infant Cereal crackersBB36. How do you know your baby is done eating? Check all that apply Turns head away Won't open his/her mouth Eats all food Bottle is empty Spits out foodBB37. Please describe any teething problems your baby may be having:BB38. Please describe any food intolerances or food allergies your baby may have:BB39. Has your baby been screened or referred for lead poisoning? Yes NoBB45. Has your child been in foster care or moved to a new foster home within the last 6 months? Yes NoBB46. Do you have any problems taking care of your baby?C1. Child's Name (First, Middle, Last)(Required)C2. Child's Date of Birth(Required)C3. Child's Gender:(Required) Boy GirlC4. Relationship to ChildC5. Child's Denali Kid Care #If applicableC6. Is this child Hispanic or Latino?(Required) Yes NoC7. Child's Race (Check all that apply)(Required) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander WhiteC8. What concerns, if any, do you have about your child's eating behaviors or growth?C9.A. What was your child's birth weight?C9.B. What was your child's birth length?C10. At what birthing facility was your child born?C11. How many weeks did your pregnancy last?C12. Are your child's immunizations up to date? Yes NoC13. Check the box if you have any of the following concerns about your child: Chewing/Swallowing Choking/Gagging Constipation Diarrhea Vomiting OtherC13.A. Please describeC14. List any medication, vitamins, mineral, or herbal supplement your child takes:C15. Please tell us if your child sees a doctor, dietitian, or health care provider for medical or emotional reasons:ex: hypertension, pre-hypertension, diabetes, fetal alcohol syndrome, gastrointestinal disorders, or anemia.C16. If your child was in the hospital in the last 3 months, please tell us why:C18. Are you currently breastfeeding your child? Yes NoC19. If breastfed, what date did breastfeeding begin?C19.A. If breastfed, what date did breastfeeding end?C20. What was the reason breastfeeding stopped?C21. If formula fed, what age (weeks or months) did you first offer?C22. On a scale of 0 to 10, how well do you think your child is eating? 0 Not Well 1 2 3 4 5 6 7 8 9 10 Very WellC22.A. How many meals does your child usually eat/day?C22.B. How many snacks does your child usually eat/day?C22.C. How many cups of fruit does your child eat per day? 1 cup or less per day 2 cups per day 3 cups or more per dayC22.D. How many cups of vegetables does your child eat per day? 1 cup or less per day 2 cups per day 3 cups or more per dayC23. Check the box if your child eats any of the following: Liquid Foods Finger Foods Table Foods Mashed, Pureed/Baby FoodsC24. Check all that apply if your child is eating any of these foods: Raw Sprouts: alfalfa, clover, and radish Raw or undercooked: meat, chicken, turkey, fish, eggs Uncooked refrigerated smoked seafood Unheated meats: lunch meats, deli-style meat or chicken, fermented and dry sausage, raw hot dogs Food with raw or undercooked eggs: salad dressing, cookie and cake batter, sauces Soft cheese made with unpasteurized milk: feta, mexican-style (queso blanco fresco), brie, blue Unpasteurized milk or foods made with unpasteurized milk Unpasteurized fruit or vegetable juiceC25. Check the box if your child drinks from any of the following: Sippy Cup Cup Baby BottleC25.A. How many baby bottles in 24 hours?C25.B. What's in the baby bottle?C26. When does your child get a baby bottle? Bedtime/Naptime Mealtime All Day OtherC26.A. Please Describe:C27. When do you want your child to only use a cup?C28. Check the box if your child regularly drinks: Water Dry Milk Whole Milk Sweet Tea 100% Pasteurized Juice Cereal/Solid Foods in a Baby Bottle Pedialyte Raw Milk 1% or 2% Milk Coffee/Tea Fruit Drink (not 100% Juice) Soy Milk Breastmilk Evaporated Milk Tang/Kool-aid Raw Juice Skim Milk Rice Milk Formula Pop/Soda Sports Drinks OtherC28.A. Describe:C29. Check if your child eats or craves any of the following: Ashes Baking Soda Burnt Matches Carpet Fibers Chalk Cigarettes Clay Dust Paint Chips Soil Starch (laundry or cornstarch) Large quantities of ice and/or freezer frostC30. Does your child eat meals with the family?C31. Is your child on a special diet?C32. Does your child have any problems eating any type of food for any reason such as dental problems, food intolerances, or others?C33. List any food allergies your child may have:C34. Has your child been screened or referred for lead poisoning? Yes NoC39. Do you have any concerns about anyone hurting your child? Yes NoC40. Has your child been in foster care or moved to a new foster home within the last 6 months? Yes NoC42. In a typical day, how much time does your child watch TV, play video games/computer games? Less than 1 hour 1-2 hours More than 2 hoursC43. Do you have any problems taking care of your child?C44. Please tell us the date of your child's last dental check-up:Month, YearC45.A. Dad's Weight:C45.B. Dad's Height:Do you need to add a 2nd child? Yes NoCC1. Child's Name (First, Middle, Last)(Required)CC2. Child's Date of Birth(Required)CC3. Child's Gender:(Required) Boy GirlCC4. Relationship to ChildCC5. Child's Denali Kid Care #If applicableCC6. Is this child Hispanic or Latino?(Required) Yes NoCC7. Child's Race (Check all that apply)(Required) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander WhiteCC8. What concerns, if any, do you have about your child's eating behaviors or growth?CC9. What was your child's birth weight?CC9.A. What was your child's birth length?CC10. At what birthing facility was your child born?CC11. How many weeks did your pregnancy last?CC12. Are your child's immunizations up to date? Yes NoCC13. Check the box if you have any of the following concerns about your child: Chewing/Swallowing Choking/Gagging Constipation Diarrhea Vomiting OtherCC13.A. Please describeCC14. List any medication, vitamins, mineral, or herbal supplement your child takes:CC15. Please tell us if your child sees a doctor, dietitian, or health care provider for medical or emotional reasons:ex: hypertension, pre-hypertension, diabetes, fetal alcohol syndrome, gastrointestinal disorders, or anemia.CC16. If your child was in the hospital in the last 3 months, please tell us why:CC18. Are you currently breastfeeding your child? Yes NoCC19. If breastfed, what date did breastfeeding begin?CC19.A. If breastfed, what date did breastfeeding end?CC20. What was the reason breastfeeding stopped?CC21. If formula fed, what age (weeks or months) did you first offer?CC22. On a scale of 0 to 10, how well do you think your child is eating? 0 Not Well 1 2 3 4 5 6 7 8 9 10 Very WellCC22.A. How many meals does your child usually eat/day?CC22.B. How many snacks does your child usually eat/day?CC22.C. How many cups of fruit does your child eat per day? 1 cup or less per day 2 cups per day 3 cups or more per dayCC22.D. How many cups of vegetables does your child eat per day? 1 cup or less per day 2 cups per day 3 cups or more per dayCC23. Check the box if your child eats any of the following: Liquid Foods Finger Foods Table Foods Mashed/Pureed/Baby FoodsCC24. Check all that apply if your child is eating any of these foods: Raw Sprouts: alfalfa, clover, and radish Raw or undercooked: meat, chicken, turkey, fish, eggs Uncooked refrigerated smoked seafood Unheated meats: lunch meats, deli-style meat or chicken, fermented and dry sausage, raw hot dogs Food with raw or undercooked eggs: salad dressing, cookie and cake batter, sauces Soft cheese made with unpasteurized milk: feta, mexican-style (queso blanco fresco), brie, blue Unpasteurized milk or foods made with unpasteurized milk Unpasteurized fruit or vegetable juiceCC25. Check the box if your child drinks from any of the following: Sippy Cup Cup Baby BottleCC25.A. How many baby bottles in 24 hours?CC25.B. What's in the baby bottle?CC26. When does your child get a baby bottle? Bedtime/Naptime Mealtime All Day OtherCC26.A. Please Describe:CC27. When do you want your child to only use a cup?CC28. Check the box if your child regularly drinks: Water Dry Milk Whole Milk Sweet Tea 100% Pasteurized Juice Cereal/Solid Foods in a Baby Bottle Pedialyte Raw Milk 1% or 2% Milk Coffee/Tea Fruit Drink (not 100% Juice) Soy Milk Breastmilk Evaporated Milk Tang/Kool-aid Raw Juice Skim Milk Rice Milk Formula Pop/Soda Sports Drinks OtherCC28.A. Describe:CC29. Check if your child eats or craves any of the following: Ashes Baking Soda Burnt Matches Carpet Fibers Chalk Cigarettes Clay Dust Paint Chips Soil Starch (laundry or cornstarch) Large quantities of ice and/or freezer frostCC30. Does your child eat meals with the family?CC31. Is your child on a special diet?CC32. Does your child have any problems eating any type of food for any reason such as dental problems, food intolerances, or others?CC33. List any food allergies your child may have:CC34. Has your child been screened or referred for lead poisoning? Yes NoCC39. Do you have any concerns about anyone hurting your child? Yes NoCC40. Has your child been in foster care or moved to a new foster home within the last 6 months? Yes NoCC42. In a typical day, how much time does your child watch TV, play video games/computer games? Less than 1 hour 1-2 hours More than 2 hoursCC43. Do you have any problems taking care of your child?CC44. Please tell us the date of your child's last dental check-up:Month, YearCC45.A. Dad's Weight:CC45.B. Dad's Height:Do you need to add a 3rd child? Yes NoD1. Child's Name (First, Middle, Last)(Required)D2. Child's Date of Birth(Required)D3. Child's Gender:(Required) Boy GirlD4. Relationship to ChildD5. Child's Denali Kid Care #If applicableD6. Is this child Hispanic or Latino?(Required) Yes NoD7. Child's Race (Check all that apply)(Required) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander WhiteD8. What concerns, if any, do you have about your child's eating behaviors or growth?D9.A. What was your child's birth weight?D9.B. What was your child's birth length?D10. At what birthing facility was your child born?D11. How many weeks did your pregnancy last?D12. Are your child's immunizations up to date? Yes NoD13. Check the box if you have any of the following concerns about your child: Chewing/Swallowing Choking/Gagging Constipation Diarrhea Vomiting OtherD13.A. Please describeD14. List any medication, vitamins, mineral, or herbal supplement your child takes:D15. Please tell us if your child sees a doctor, dietitian, or health care provider for medical or emotional reasons:ex: hypertension, pre-hypertension, diabetes, fetal alcohol syndrome, gastrointestinal disorders, or anemia.D16. If your child was in the hospital in the last 3 months, please tell us why:D18. Are you currently breastfeeding your child? Yes NoD19. If breastfed, what date did breastfeeding begin?D19.A. If breastfed, what date did breastfeeding end?D20. What was the reason breastfeeding stopped?D21. If formula fed, what age (weeks or months) did you first offer?D22. On a scale of 0 to 10, how well do you think your child is eating? 0 Not Well 1 2 3 4 5 6 7 8 9 10 Very WellD22.A. How many meals does your child usually eat/day?D22.B. How many snacks does your child usually eat/day?D22.C. How many cups of fruit does your child eat per day? 1 cup or less per day 2 cups per day 3 cups or more per dayD22.D. How many cups of vegetables does your child eat per day? 1 cup or less per day 2 cups per day 3 cups or more per dayD23. Check the box if your child eats any of the following: Liquid Foods Finger Foods Table Foods Mashed/Pureed/Baby FoodsD24. Check all that apply if your child is eating any of these foods: Raw Sprouts: alfalfa, clover, and radish Raw or undercooked: meat, chicken, turkey, fish, eggs Uncooked refrigerated smoked seafood Unheated meats: lunch meats, deli-style meat or chicken, fermented and dry sausage, raw hot dogs Food with raw or undercooked eggs: salad dressing, cookie and cake batter, sauces Soft cheese made with unpasteurized milk: feta, mexican-style (queso blanco fresco), brie, blue Unpasteurized milk or foods made with unpasteurized milk Unpasteurized fruit or vegetable juiceD25. Check the box if your child drinks from any of the following: Sippy Cup Cup Baby BottleD25.A How many baby bottles in 24 hours?D25.B. What's in the baby bottle?D26. When does your child get a baby bottle? Bedtime/Naptime Mealtime All Day OtherD26.A. Please Describe:D27. When do you want your child to only use a cup?D28. Check the box if your child regularly drinks: Water Dry Milk Whole Milk Sweet Tea 100% Pasteurized Juice Cereal/Solid Foods in a Baby Bottle Pedialyte Raw Milk 1% or 2% Milk Coffee/Tea Fruit Drink (not 100% Juice) Soy Milk Breastmilk Evaporated Milk Tang/Kool-aid Raw Juice Skim Milk Rice Milk Formula Pop/Soda Sports Drinks OtherD28.A. Describe:D29. Check if your child eats or craves any of the following: Ashes Baking Soda Burnt Matches Carpet Fibers Chalk Cigarettes Clay Dust Paint Chips Soil Starch (laundry or cornstarch) Large quantities of ice and/or freezer frostD30. Does your child eat meals with the family?D31. Is your child on a special diet?D32. Does your child have any problems eating any type of food for any reason such as dental problems, food intolerances, or others?D33. List any food allergies your child may have:D34. Has your child been screened or referred for lead poisoning? Yes NoD39. Do you have any concerns about anyone hurting your child? Yes NoD40. Has your child been in foster care or moved to a new foster home within the last 6 months? Yes NoD42. In a typical day, how much time does your child watch TV, play video games/computer games? Less than 1 hour 1-2 hours More than 2 hoursD43. Do you have any problems taking care of your child?D44. Please tell us the date of your child's last dental check-up:Month, YearD45.A. Dad's Weight:D45.B. Dad's Height: