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2. 
4. Families living in Chisago County may receive a Public Health Nurse home visit.

   Public Health Nurses check the health status of families, weigh & measure infants and children, work with other community resources and answer any questions you may have about:  your pregnancy, labor & delivery, breastfeeding, how to calm a fussy baby, when to start solid foods, how to encourage the growth and development of your child, family planning/child spacing, how to make your home safer for your family, and community resources available to support your family.

6. Please send an email to mchnurses@chisagocountymn.gov with any questions.
8. Primary Caregiver Information:
10. Last Name:*
11. First Name:*
12. Middle Initial
13. Date of Birth:
    Date of Birth:
15. Street Address:*
16. City:*
17. Zip Code:*
19. Phone Number:*
20. OK to leave message?*

    1. Yes
    2. No
21. OK to text?*

    1. Yes
    2. No
23. Is client aware of referral?*

    1. Yes
    2. No
24. Interpreter Needed?*

    1. No
    2. Yes
25. Language:
27. Family would benefit from support related to (check all that apply):*

    1. Pregnancy
    2. Postpartum - Delivered Baby in last 6 weeks
    3. Parenting
29. Currently Pregnant?*

    1. Yes
    2. No
30. Is this a 1st Baby?

    1. Yes
    2. No
31. Due Date:
    Due Date:
33. Children in household:
35. Name Child 1:
36. Date of Birth Child 1:
    Date of Birth Child 1:
37. Sex Child 1:

    1. Male
    2. Female
    3. Unknown
39. Name Child 2:
40. Date of Birth Child 2:
    Date of Birth Child 2:
41. Sex Child 2:

    1. Male
    2. Female
    3. Unknown
43. Name Child 3:
44. Date of Birth Child 3:
    Date of Birth Child 3:
45. Sex Child 3:

    1. Male
    2. Female
    3. Unknown
47. Name Child 4:
48. Date of Birth Child 4:
    Date of Birth Child 4:
49. Sex Child 4:

    1. Male
    2. Female
    3. Unknown
51. Comments:
53. Referring Agency:
54. Date:
    Date:
56. Person Making Referral/Title:
57. Phone Number:
Leave This Blank:


59. Submit

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