Lactation Consultation Intake Form
feeding dyad history
Email *
First and last name (pronouns if applicable): *
Infant's first and last name *
Infant's date of birth *
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Infant's due date *
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Full Address (this will only be used to get to your home for the consultation) *
phone number
Delivering hospital *
return to work?
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How long is your maternity leave? Will you return full-time or part-time?
Infant's peditrician (name of practice, name of doctor/practitioner/phone number / fax number) *
Do I, Dominique Gallo,  have permission to fax your child's peditrician information from the consultation (baby's weight, the feeding plan, and any findings pertaining to the feed) No parent information will be shared with the peditrician unless there is a medication that requires infant monitoring. *
Type of delivery? *
Gestational age of baby at delivery? (how many weeks pregnant at delivery?) *
Baby's birth weight, discharge weight, and current weight  *
Did you receive antibiotics in the hospital? *
Difficulty with feeding in the hospital? *
If you did have difficulties, can you please describe what happened to the best of your ability?
Did you use a nipple shield in the hospital? *
Did you have to pump in the hospital? *
Did the infant have to be supplemented in the hospital (human milk and/or formula)? *
If you had to supplement, what method of feeding did you use?
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If you had to supplement, what was your reason?
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