Beneficiary’s Name: Parent/Guardian:
Date Infant Risk Identifier Completed: Date of Birth:
Number Visits: Infant Services Completed? Date: Not Completed Cannot be Located
Parent/Guardian Declined Services: Reason:
Family Moved: To: Client’s MIHP Care Transferred To:
The following chart addresses the initial risk(s) identified at enrollment in MIHP and current or ongoing risk(s).
Key: R = Initial Risk S = Summary
N = No L = Low M = Moderate
H = High U = Unknown
Risk /Intervention / N / L / M / H / U
/ Progress During Infant Interventions
Infant Health / R
S
/ Seen by medical provider: Regularly Illness only Sporadic
Location of medical provider: Clinic/office ER/ urgent care
Other Describe :
Receiving WIC services: Yes No
Receiving Children’s Special Health Care Services (CSHCS): Yes No
Immunization up to date: Yes No
Infant health education provided: Yes No Referred : Yes No
Infant Safety / R
S
/ Sleeps in Crib: Yes No On back: Yes No
Co sleeps with someone: Yes No
Car seat: Yes No
Lead risk: Yes No
2nd hand smoke: Yes No
Guns/weapons in home: Yes No
CPS referral: Yes No Current open CPS case? Yes No
Infant safety education provided: Yes No Referred : Yes No
Feeding and Nutrition / R
S
/ Infant fed primarily: Breast milk Formula Solid food Other
Describe:
Ever breast fed: Yes No If yes, how long:
Sleeps with bottle: Yes No
Plans for dentist: Yes No
Receiving WIC services: Yes No
Feeding and nutrition education provided: Yes No Referred: Yes No
Infant Development / R
S
/ Referred by MIHP to Early On®: Yes No
Receiving Early On® services: Yes No
Infant development education provided: Yes No Referred: Yes No
Family Support (Parenting and Childcare) / R
S
/ Can identify minimum of one support person: Yes No
Family support education provided: Yes No Referred: Yes No
Family, Living Arrangement, Language and Environmental Considerations Noted and Addressed:

Maternal Infant Health Program (MIHP)

Infant Discharge Summary for Medical Care Provider

Group Parenting Education: Provided Referred Attended? Yes No Unknown Refused
Currently Breastfeeding? Yes No Unknown
Immunization Schedule: Education Provided Referred Refused Well Child Schedule: Education Provided Referred Refused

Referrals Made For Family During Care: Family Planning Plan FIRST! Immunization Medical Dental Counseling

Infant Mental Health Parenting Support Child care WIC Substance Abuse Services Child Protective Services (CPS)

Domestic Violence Services Home Visitation/Support Program Describe:

Other Describe:

Additional Comments:

MIHP Agency:

Name (print or type):

Signature and credentials: Date:

MIHP I015 – 1.1.11v2