Number of weeks for “How old was infant when he/she was first fed formula?” Number of weeks for “How old was infant when he/she was fed formula on a regular basis?” Number of weeks for “How old was infant when he/she completely stopped breastfeeding or being fed breastmilk?” Reason for “What was your reason for stopping breastfeeding?” BF Description if value = “No Longer BF” or “Never BF”. If there is a previous Child Interview record, carry forward the following data from the previous interview: any Medical Condition (Risks 341-362) with the exception of 359-Recent surgery and 352 – Infectious disease the number of DTaP shots recorded on the previous interview Number of weeks for “How old was infant (child) when he/she completely stopped breastfeeding or being fed breastmilk?” This maps to “How old was child when he/she completely stopped breastfeeding or being fed breast milk?” Reason for “What was your reason for stopping breastfeeding?” BF Description if value = “No Longer BF” or “Never BF”. When the Change BF Info button is clicked, display a confirmation message “You are about to change the Breastfeeding Status of this Nutrition Interview. This clears the answers of the questions that relate to the Breastfeeding Description. Do you want to continue?” Yes/No
Display Only No Calculated No DB Column InfantInterviewRisk.PRC_ID 1c. If bottle feeding, listen, ask, and assess for Amount of breastmilk/formula Ounces/bottle and bottles/day Formula brand/type How is formula mixed Water source Contents other than breastmilk/formula Storage/handling The text is displayed in the left portion of the main to help the user interview in a client-centered way in order to obtain a quality nutrition assessment. Type Text Box Display Only Yes Calculated No DB Column NA 1d. What besides breast milk has <baby’s name> received? This provides an opportunity to define what, if anything, has been consumed by the infant besides breast milk. Type List Box Required Yes, for all Infants DB Column InterviewInfant.BreastmilkOtherCd Code ID Breastmilk Other This code element is non-editable. The installed values are: Nothing Something else, rarely Something else, regular 1e. How old was <baby’s name> when he/she was fed something other than breast milk? The text is displayed in the left portion of the main panel to help the user interview in a client-centered way in order to obtain a quality nutrition assessment. Type Text Box
Child – Oral Health > Assessment > Nutrition Interview <Family Header (See CS Overview)> <Participant Sub-Header (See CS Overview)> Control Description 3a. How do you take care of <child’s name>’s teeth? The text is displayed in the left portion of the main panel to help the user interview in a client-centered way in order to obtain a quality nutrition assessment. Type Text Box Display Only Yes Calculated No DB Column NA (unlabeled) This is subjective information collected from the interview. The text entered into this text box is displayed in the Subjective portion of the Participant Care Plan. The maximum number of characters allowed is 500. Type Multi Line Text Box Required No Display Only No Calculated No DB Column InterviewChild.OralHealthTextbox1 3b. Has <child’s name> seen a dentist? - Yes This radio button indicates that the child has seen a dentist. Type Radio Button Required No DB Column InterviewChild.DentistIn 3b. Has <child’s name> seen a dentist? - No This radio button indicates that the child has not seen a dentist. Type Button Required No DB Column InterviewChild.DentistIn 381 - <Risk Description> If this check box is marked, then this risk is auto-assigned during the risk determination process. The Risk Description is defined in System Administration. Type Check Box Display Only No Calculated No
Control Description 4a. What types of activities does <Child’s Name> enjoy? The text is displayed in the left portion of the main panel to help the user interview in a client-centered way in order to obtain a quality nutrition assessment. Type Text Box Display Only Yes Calculated No DB Column NA (unlabeled) This is subjective information collected from the interview. The text entered into this text box is displayed in the Subjective portion of the Participant Care Plan. The maximum number of characters allowed is 500. Type Multi Line Text Box Required No Display Only No Calculated No DB Column InterviewChild.LifeStyleTextbox1 4b. # hours of TV watching/video playing per day This is the number of hours per day that the child spends watching TV or playing video games. Type Text box Required No Length 2 Validation Numeric, Mask of Z9, range is 0-24 Display Only No Calculated No DB Column InterviewChild.TVHourNr 4c. Does anyone living in your household smoke inside the home? - Yes This radio button indicates that someone in the household smokes. Type Radio Button Required No DB Column InterviewChild.HouseholdSmokeIn 4c. Does anyone living in your household smoke inside the home? - No This radio button indicates that no one in the household smokes. Type Radio Button Required No DB Column InterviewChild.HouseholdSmokeIn
1f. How old was <baby’s name> when he/she was fed something else on a regular basis? Text box, # of weeks (acceptable values between 0-52) Carry this value forward to subsequent interviews (including child interview). Prevalence reports 1g. How much formula has <baby’s name> received? List box None Some formula, rarely Some formula, regular basis To manage data collection and required fields in MPSC system. 1h. How old was <baby’s name> when he/she was first fed formula? Text box, # of weeks (acceptable values between 0-52) Carry this value forward to subsequent interviews (including child interview). Rapport, reports 1i. How old was <baby’s name> when he/she was fed formula on a regular basis (not a rare or occasional circumstance)? Text box, # of weeks (acceptable values between 0-52) this value forward to subsequent interviews (including child interview). Rapport 1j. What else do you feed [baby’s name]? Listen, ask, and assess for Early introduction of solids Developmentally appropriate foods Cup feeding – type, use, contents Anything that is discovered in this question could be entered in the text box above. Risk assignment is below. Rapport 1k. What led to <baby’s name> getting other food/drink? Text box Contents of text box go to S portion of care plan. To collect for understanding why infants who as exclusively breastfeeding get something else.
Nutrition Practices (Not Breastfeeding) # Question Response Action Purpose Main Panel 2a. Breastfeeding description List box Excl BF Prim Excl BF / No WIC Excl / Comp Part BF BF Child No Longer BF Never BF If No Longer BF, then enable 2b and 2c, required if Infant. Needed for system participant profiles, multiple reports PNSS, PedNSS, PC Report 2b. How old was <baby’s name> when he/she completely stopped breastfeeding or being fed breast milk? Text box # of weeks (acceptable values between 0-52) Bring this value forward on subsequent interviews (including child interviews). Required if Breastfeeding description = No Longer BF and Infant. CDC data collection related to breastfeeding duration. 2c. What was your main reason for stopping breastfeeding? List box State defined list of reasons Bring this value forward on subsequent interviews (including child interviews). Required if Breastfeeding description = No Longer BF and Infant. Data collection for MPSC breastfeeding ceased reason report.
2d. How old was <baby’s name> when he/she was first fed something other than breast milk? Text box, # of weeks (acceptable values between 0-52) Required Carry this value forward to subsequent interviews (including child interview). CDC data collection related to exclusive breastfeeding and duration. 2e. How old was <baby’s name> when he/she was fed something else on a regular basis? Text box, # of weeks (acceptable values between 0-52) Carry this value forward to subsequent interviews (including child interview). Prevalence reports 2f. How much formula has <baby’s name> received? List box None Some formula, rarely Some formula, regular basis To manage data collection and required fields in MPSC system. 2g. How old was <baby’s name> when he/she was first fed formula? Text box, # of weeks (acceptable values between 0-52) this value forward to subsequent interviews (including child interview). Rapport, reports 2h. How old was <baby’s name> when he/she was fed formula on a regular basis (not a rare or occasional circumstance)? Text box, # of weeks (acceptable values between 0-52) Carry this value forward to subsequent interviews (including child interview). Rapport, reports 2i. Tell me how it is feeding <baby’s name>. Listen, ask, and assess for Hunger and satiety cues Number of wet/dirty diapers Appetite changes Constipation or diarrhea Vomiting Text box Contents of text box go to S portion of care plan. Rapport, Risk 603,
Health/Medical # Question Response Action Purpose Main Panel 3a. What concerns do you have about <baby’s name>’s health? Concerns: Text box Contents of text box go to S portion of care plan. Rapport 3b. Does <baby’s name> have any medical problems diagnosed by a doctor? Radio buttons: Conditions/No Conditions If Conditions, then enable Medical Conditions check boxes. Process
Medical Conditions 347 - Cancer, affects nutritional status 354 - Celiac disease 348 - Central nervous system disorders <Condition list box> 381 - Dental problems 362 - Developmental delays, sensory or motor delays interfering with ability to eat 343 - Diabetes mellitus 134 - Failure to thrive 382 - Fetal Alcohol Syndrome 353 - Food allergies, please list: <Text box> 342 - Gastrointestinal disorder <Condition list box> 349 - Genetic and congenital disorders <Condition list box> 345 - Hypertension 356 - Hypoglycemia 351 - Inborn error of metabolism <Condition list box> 352 - Infectious disease, affects nutritional status <Condition list box> 355 - Lactose intolerance, diagnosed 341 - Nutrient deficiency disease <Condition list box> 359 - Recent major surgery (including C-sections), trauma, or burns severe enough to affect nutritional status <Text box> 901 - Recipient of abuse in the past 6 months 346 - Renal disease <Condition list box> 151 - Small for gestational age 344 - Thyroid disorder 360 - Other, medical conditions severe enough to affect nutritional status <Condition list box> If condition has a checkbox and a list box, the list box is enabled when the user the checkbox. I list box selection is then required. Central nervous system disorders list box values: Epilepsy Cerebral palsy (CP) Neural tube defects (NTD) Spina Bifida Myelomeningocele Parkinson’s disease Multiple Sclerosis (MS) Gastrointestinal disorder list box values: Gastroesophageal reflux disease (GERD) Peptic ulcer Post-bariatric surgery Short bowel syndrome Inflammatory bowel disease (UC and Chron’s) disease Pancreatitis Biliary tract diseases Genetic and congenital disorders list box values: lip or palate Down syndrome Thalassemia major Assign risk based on medical condition marked. Carry specific medical condition to A section of care plan. risks 341-362 (except 352 and 359) forward to subsequent interviews (including child interview). Risks - 134, 341, 342, 343, 344, 345, 346, 347, 348, 349, 351, 352, 353, 354, 355, 356, 357, 359, 360, 362, 381, 382, 901, 902
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
Medical Conditions 347 - Cancer, affects nutritional status 354 - Celiac disease 348 - Central nervous system disorders <Condition list box> 381 - Dental problems 361 - Depression 362 - Developmental delays, sensory or delays interfering with ability to eat 343 - Diabetes mellitus 134 - Failure to thrive 382 - Fetal Alcohol Syndrome 353 - Food allergies, please list: <Text box> 342 - Gastrointestinal disorder <Condition list box> 349 - Genetic and congenital disorders <Condition list box> 345 - Hypertension 356 - Hypoglycemia 351 - Inborn of metabolism <Condition list box> 352 - Infectious disease, affects nutritional status <Condition list box> 355 - Lactose intolerance, diagnosed 341 - Nutrient deficiency disease <Condition list box> 359 - Recent major surgery (including C-sections), trauma, or burns severe enough to affect nutritional status (describe): <Text box> 901 - Recipient of in the past 6 months 346 - Renal disease <Condition list box> 151 - Small for gestational age 344 - Thyroid disorder 360 - Other, medical conditions severe enough to affect nutritional status <Condition list box> If condition has a checkbox and a list box, the list box is enabled when the user the checkbox. I list box selection is then required. Central nervous system disorders list box values: Epilepsy Cerebral (CP) Neural tube defects (NTD) Spina Bifida Myelomeningocele Parkinson’s disease Multiple Sclerosis (MS) Gastrointestinal disorder list box values: Gastroesophageal reflux disease (GERD) Peptic ulcer Post-bariatric surgery Short bowel syndrome Inflammatory bowel disease (UC and Chron’s) Liver disease Pancreatitis Biliary diseases Genetic and congenital disorders list box values: Cleft lip or palate Down syndrome Thalassemia Assign risk based on medical condition marked. Carry specific medical condition to A section of care plan. Carry risks 341-362 (except 352 and 359) forward to subsequent interviews (including child interview). Risks 134, 341, 342, 343, 344, 345, 346, 347, 348, 349, 351, 352, 353, 354, 355, 356, 357, 359, 360, 361, 362, 381, 382, 901
1d. Biological mother Current Weight Height Current BMI information forward and display if mother on WIC and data is available. Text box lbs. Text box inches Text box Calculation Risk 1e. Biological father Current Weight Height Current BMI Text box lbs. Text box inches Text box Calculation Risk Bottom Panel