New Client Health History Form

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Please complete this form the best of your ability. There are some personal questions, if you would rather tell me verbally, that is perfectly fine. Each of these questions help me have a better understanding of your breastfeeding situation. I am here to help you and the more I know, the better I am able to do that. This Google Form is HIPAA compliant and your information is kept private.

I ask for your health insurance information to include on the "ICD-10 Superbill" that I will provide to you. You can submit this to your health insurance company for reimbursement.

Your Name *

Home Address *

Email Address *

Phone Number *

Your date of birth *

YYYY

For many of my clients, the appointment is fully covered by health insurance through my partnership with The Lactation Network. Was your insurance approved with The Lactation Network. *

Yes, I received an approval email from The Lactation Network.

No, I will be a "cash pay" client and have reviewed the payment policy. I would like to received a "superbill" to submit to my insurance for reimbursement.

No, I will a "cash pay" client and do not have health insurance or have a Medicaid plan and do not need a "superbill"

Please confirm that you have access to our Privacy Policy on our website. If not, we are happy to provide a printed copy.

Yes, I have reviewed the Privacy Policy online

No, I have not reviewed the Privacy Policy. Please email me a copy.

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In order to comply with HIPAA guidelines, communication must be through a secure service. Communication via email, text and social media are not secure private communications. Please select your preference. *

Please adhere to HIPAA guidelines and communicate with me only through phone call or secure online storage (I use Google Drive for healthcare providers and can provide access via your Google gmail address)

I waive my right to secure communications. Please communicate with me via email, text and social media.

I prefer all communications occur via phone or USPS mail only.

In accordance with professional guidelines for lactation consultants, I provide a report to your care providers (OB, midwife, pediatrician). I copy is also available for you. If you prefer, I can not report to your other healthcare providers. *

Yes, please communicate with our primary care providers.

No, please do not communicate with our primary care providers.

OB/GYN, Midwife or Primary Care Provider *

Pediatrician *

What concerns do you have related to breastfeeding? *

How did you learn about me? *

Number of children you have given birth to? Describe any previous breastfeeding experience. *

Your height *

Your pre-pregnancy weight *

Your age *

What vitamins, supplements, herbs, or special diet are you using? *

Do you have a history of any of the following? Check all that apply and we will discuss in more detail during your appointment. These things may not have an impact on breastfeeding. *

Injury to Chest as child or adolescent

Breast Biopsy

Any Breast Surgery

Breast Cyst

Hypertension (High Blood Pressure)

Anemia

Type 1 Diabetes

Type 2 Diabetes

Gastric Bypass Surgery

Damage to Nerves or Spinal Cord

Thyroid Irregularity

Any Hormone Irregularity

Infertility

Luteal Phase defect

Unusual Shape Breast or Nipple

No breast changes during pregnancy

Eating Disorder

Sexual or Physical or Emotional Abuse Abuse/Trauma

Placental Insufficiency

Retained Placenta

Postpartum Hemorrhage (Excessive Blood Loss) at birth or during the days or weeks following

PCOS

Gestational Ovarian Theca Lutein Cysts

Breast Infection (Mastitis)

Anxiety or Depression

Placental Abruption

Other Chronic Illness or Condition

Other:

Required

Estimated due date *

YYYY

Baby's planned location of birth (name of hospital or home) *

Describe any particular birth plans or expectations. *

What are your breastfeeding goals? *

Will you be working after baby's birth? At what age will you go to work? *

Any other information about you or your baby that may help me understand your situation better?

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