Life Style # Question Response Action Purpose Main Panel 6a. How active is <baby’s name> every day? Text box Contents of text box go to Rapport Listen, ask, and assess for time spent in: S portion of care plan. Strollers Play pens Infant seats Car seats Listen, ask, and assess for planned physical activity times for: Crawling Rolling over Moving muscles (massage) Walking 6b. Does anyone living in your household smoke inside Radio buttons: PedNSS, Risk 904 the home? Yes No 6c. What else can I help you with? Text box Contents of text box go to Risks 902, Referral Listen, ask, and assess for S portion of care plan. Abuse/neglect in the last 6 months Limited ability to make appropriate feeding decisions or prepare foods 902 - Primary caregiver with limited ability to prepare food Bottom What kinds of activities do you and your family do Conversation together? starter Mom’s WIC Participation # Question Response Action Purpose Main Panel 7a. Was mother on WIC during her pregnancy? Radio buttons: If No, then enable 7b Risk 701 Yes No
Life Style # Question Response Action Purpose Main Panel 6a. How active is <baby’s name> every day? Listen, ask, and assess for time spent in: Strollers Play pens Infant seats Car seats Listen, ask, and assess for planned physical activity times for: Crawling Rolling over Moving muscles (massage) Walking Text box Contents of text box go to S portion of care plan. Rapport 6b. Does anyone living in your household smoke inside the home? Radio buttons: Yes No PedNSS, Risk 904 6c. What else can I help you with? Listen, ask, and assess for Abuse/neglect in the last 6 months Limited ability to make appropriate feeding decisions or prepare foods 902 - Primary caregiver with limited ability to prepare food Text box Contents of text box go to S portion of care plan. Risks 902, Referral Bottom What kinds of activities do you and your family do together? Conversation starter Mom’s WIC Participation # Question Response Action Purpose Main Panel 7a. Was mother on WIC during her pregnancy? Radio buttons: Yes No If No, then enable 7b Risk 701
DFDD%20CS%203c%20Assessment%20-%20Interview%20Screens%20-%20I%20and%20C.docx