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Get CA CDPH 247A 2010-2021

With WIC eligibility, WIC services, and appropriate referrals. Whenever a therapeutic formula or medical food is prescribed, complete both Sections I and II. PATIENT NAME (First) (Last) CURRENT HEIGHT/LENGTH: _________ inches (within 60 days) DATE OF BIRTH: CURRENT WEIGHT: _____ lb _____ oz (within 60 days) CURERNT BMI: BMI percentile: ______ % (within 60 days) HEMOGLOBIN OR HEMATOCRIT TEST is required every 12 months when normal and every 6 months when abnormal. Hemoglobin (gm/dl) or Hema.

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