Get CA CDPH 247A 2016-2021
ID#: SECTION I: omplete this section to assist the patient with WIC eligibility, WIC services, and appropriate referrals. Whenever a therapeutic formula is prescribed, complete both Sections I and II. PATIENT NAME: (First) CURRENT HEIGHT/LENGTH: (within 60 days) (Last) CURRENT WEIGHT: (within 60 days) lbs inches oz DATE OF BIRTH: CURRENT BMI: (within 60 days) BMI percentile: MEASUREMENT DATE: lbs % HEMOGLOBIN OR HEMATOCRIT TEST is required every 12 months when normal LEAD TEST.
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