M4-THEO

MIECHV ENROLLMENT FORM

Index Child

INDEX CHILD’S Enrollment Date:	/ / 20

Name of Home Visitor:

Home Visiting Program:	Early Head Start	Healthy Families Oregon

Parent ID#:

Name of Index Parent:

INDEX CHILD ID #:

First, Middle, and Last Name of INDEX CHILD:

First	Middle	Last

Child Client Record/Demographics:

(Questions A-E will ONLY be entered on the Client Intake screen during the Client Application/Enrollment process in THEO – NOT in the M4 Survey)

A.	Date of Birth:	/ / 20

B.	Gender:	Female	Male	X (Non-binary)	Declined to self-identify

C.	Primary Language:	English	Spanish	Other language:

D.	Ethnicity:	Not-Hispanic or Not-Latino/a	Hispanic or Latino/a Declined to self-identify Unknown

E.	Race (Check all that apply):

American Indian/Alaska Native	White/Caucasian

Asian	Unknown

Black or African American	Declined to self-identify

Native Hawaiian/Other Pacific Islander

Questions about Index Child:

1.	Completed weeks of gestation at birth:	Weeks

2.	Has child ever had any breast milk?	Yes → Go to Question 2a.	No → Go to Question 3.

2a.	If Yes, does child continue to get any breast milk?

Yes → Go to Question 3.	No → Go to Question 2b.

2b.	If No, date child stopped getting breast milk:	/ / 20

3.	Child’s current health Insurance status:

Not insured	State Children’s Insurance Program (SCHIP)

Private or employer’s Insurance	TRICARE or other military health care

OHP/Medicaid	Other insurance

M4-THEO

MIECHV ENROLLMENT FORM, continued

Index Child	ID# __________________

4.	Has your child had a well-child visit? Yes → Go to Question 4a.	No → Go to Question 5.

4a. If yes, select the most recent well-child visit.

3 -5 days 4 months

1 month 6 months

2 months 9 months

12 months 24 months

15 months 30 months

18 months

5. Where do you usually take your child for medical care?

Doctor’s/Nurse Practitioner’s Office

Hospital Emergency Room

Hospital Outpatient

Federally Qualified Health Center (FQHC)

Retail Store or Minute Clinic

Other:

6.	Does your child have a usual source of dental care?	Yes	No

7. How often do you place your infant to sleep on their back?

Always

Sometimes

Never

8. How often do you bed-share with your infant?

Always

Sometimes

Never

9. How often does your infant sleep with soft bedding?

Always

Sometimes

Never

10.	During a typical week, how many days do you (and/or a family member) read, tell stories and/or sing songs to your child?

0 – Not at all 1 2 3 4 5 6 7 – Every day