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Prenatal Intake Form
Please provide the following information to the best of your knowledge. We'll go over it all when we meet!
Thanks,
Erica Charpentier, IBCLC
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Expectant parent's first and last name
Your answer
Consult date
MM
/
DD
/
YYYY
Expectant parent's date of birth
MM
/
DD
/
YYYY
Due date
MM
/
DD
/
YYYY
Expectant parent's address
Your answer
Expectant parent's phone number
Your answer
Expectant parent's email address
Your answer
Partner's first and last name
Your answer
Partner's phone number
Your answer
Midwife or OB's name and practice
Your answer
Midwife or OB's phone number
Your answer
Pediatrician's name and practice (if known)
Your answer
Pediatrician's phone number (if known)
Your answer
What is your occupation?
Your answer
If you are returning to work outside the home after giving birth, when will you return?
Your answer
Any history of:
thyroid condition
ovacrian cyst
PCOS
diabetes
Other:
What medications are you currently taking? (including herbs and vitamins)
Your answer
Do you plan on consuming any form of placenta?
Yes
No
Other:
Clear selection
Have you ever had a breast or chest surgery or injury? If yes, please describe in "other," including the approximate date.
Yes
No
Other:
Clear selection
Did you conceive easily?
Yes
No
Clear selection
Did you conceive with any of the following:
IVF
IUI
IUI - donated sperm
IUI - donated egg
Other:
Clear selection
Do you have a history of miscarriages?
Yes
No
Clear selection
If yes, was a reason determined?
Your answer
Including your current pregnancy, how many times have you been pregnant?
Your answer
How many other children have you breastfed?
Your answer
How long have your other child(ren) breastfed?
Your answer
How did breastfeeding go with your older child(ren)?
Your answer
During this pregnancy, have you experienced any of these breast changes?
enlargement
tenderness
darkening of the areola
leaking
Other:
Have you ever been on bed rest? If so, please describe in "other".
No
Other:
Clear selection
Any complications during your pregnancy?
Your answer
Are you pregnant with multiples?
Option 1
Twins
Triplets
Other:
Clear selection
Where do you plan on delivering?
Your answer
Do you have a doula?
Yes, a birth doula
Yes, a postpartum doula
No
Clear selection
Do you have a birth plan? Include any methods (Bradley, hypnobirthing, etc.)
Your answer
Will you be having a scheduled C-section birth?
No
Yes - Breech
Yes - Repeat C-section birth
Other:
Clear selection
If you have given birth before, please describe your experience.
Your answer
If you have read any breastfeeding books or resources, please list them here.
Your answer
If you have prior breastfeeding experience, please describe here.
Your answer
If you experienced any unusual breast development in puberty, please describe here.
Your answer
Do you plan on having your baby circumcised? If so, please indicate the day of circumcision.
Your answer
If you have a pump, what brand of pump and what flange size (imprinted on side of flange)?
Your answer
Is your pump owned or rented?
owned
rented
Other:
Clear selection
If owned, is it a new pump, or used before with another child?
new
used
Other:
Clear selection
Where do you plan on your baby sleeping?
in my bed
in my room, in a cosleeper
in my room in a crib/bassinet
in his/her own room
Other:
Clear selection
For how long do you see yourself breastfeeding?
Your answer
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