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Breastfeeding Intake Form
DyAnna Gordon- Complete Beginnings Consultations
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Option 1
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Mother's First Name
Your answer
Mother's Last Name
Your answer
Baby's First Name
Your answer
Baby's Last Name
Your answer
Baby's date of birth
MM
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DD
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YYYY
Baby's weight at birth
Your answer
Baby's weight at discharge
Your answer
Baby's most recent weight, and was it on the same scale
Your answer
Is this baby adopted?
Yes
No
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This baby's pregnancy
Column 1
Gestational Diabetes
Pre-eclampsia
Infertility
Preterm birth
Not applicable
Column 1
Gestational Diabetes
Pre-eclampsia
Infertility
Preterm birth
Not applicable
This baby's birth
Column 1
Vaginal delivery
Induction
Epidural
Forceps/vacuum
Cesarean Birth
Gestational Diabetes
Pre-eclampsia
Preterm birth
Postpartum hemorrhage
Unknown
Column 1
Vaginal delivery
Induction
Epidural
Forceps/vacuum
Cesarean Birth
Gestational Diabetes
Pre-eclampsia
Preterm birth
Postpartum hemorrhage
Unknown
Baby's health history- select all that apply
Jaundice
NICU stay
Breathing issues
Feeding issues
Temperature issues
Low blood sugar
Not Applicable
Other:
Was this baby born premature?
Yes
No
Clear selection
If born premature, what was the baby's gestation?
Your answer
Is you baby taking any artificial baby milk?
No, all nutrition from my own breastmilk
No, all nutrition from breastmilk including donor milk
Yes, all nutrition from formula
Some, some formula is given
Some formula given in the past but baby is no longer taking formula
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Was your baby given formula in the hospital if yes, why?
Your answer
If you have and or using a breast pump please share what type you have and what size of flange you are currently using
Your answer
Current breastfeeding concerns:
Latch on difficulties
Low milk supply
Over supply of milk
Mastitis
Nipple pain
Yeast infection/thrush/candida
Recurrent plugged ducts
Baby with tongue tie
GERD or reflux
Slow weight gain
Weight loss
Cracked nipple
Milk "never came in"
Fussy baby
Baby unsatisfied after a feeding
Breast pump dependant
Breast pain
Sleepy baby
Engorgement
Green or foamy stools
Pulling off the breast while feeding
Nipples turn white after feeding
Pumping concerns
Other:
If baby is on the breast, do you have a preferred position for feeding?
Cradle hold
Cross cradle hold
Football hold
Laid back hold
Side lying hold
other
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Have you noticed
Your breasts softening after a feeding?
Your baby swallowing during a feeding?
Not applicable
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How many times has your baby breastfed in the last 24 hours?
Choose
1
2
3
4
5
6
7
8
9
10
11
12+
Not applicable
How long does the baby usually feed at the breast?
Choose
10 minutes or less
10-15 minutes
15-20 minutes
20-30 minutes
30-45 minutes
An hour or more
Not applicable
How long in between feedings in minutes?
Choose
30 minutes to 60 minutes
60 minutes to 120 minutes
120 minutes to 180 minutes
180 minutes to 240 minutes
Greater than 4 hours between feedings
Not applicable
How many wet diapers in the last 24 hours?
Choose
1
2
3
4
5
6
7
8
9
10
Not applicable
How many soiled diapers in the last 24 hours?
Choose
1
2
3
4
5
6
7
8
9
10
Not applicable
Who referred you to this office?
Your answer
Relationship status
Spouse
Partner
Single
Other:
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Do you have help at home?
Yes
No
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Occupation
Your answer
Do you work outside the home?
Yes
No
Part-time
Other:
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Have you or are you returning to work? If so please select when, if not select 01/01/2025
MM
/
DD
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YYYY
Number of pregnancies
Choose
1
2
3
4
5
6
7
8
9
Not applicable
Number of children
Choose
1
2
3
4
5
6
7
8
9
Not applicable
Did you breastfeed other children? If so for how long?
Your answer
Did you have any of these difficulty with breastfeeding your other children
Low milk supply
Over supply of milk
Mastitis
Nipple pain
Yeast infection/thrush/candida
Recurrent plugged ducts
Baby with tongue tie
GERD or reflux
Other
No problems
No other children
Current and Past Medical History
Your answer
Reproductive health
Irregular periods
Infertility
PCOS
IVF
Other:
Breast Health
Breast augmentation
Breast reduction
Breasts did not grow during pregnancy
Breast cancer
One breast much larger than the other
Biopsy
Fibrocystic breasts
Nipple piercing
Flat nipples
Inverted nipples
Other:
Medical History
Panic attacks
Depression
Post-Partum Depression
Anxiety disorder
Food sensitivities
Seasonal allergies
Diabetes
Hyperthyroidism
Hypothyroidism
Other thyroid problems
Breast augmentation
Breast reduction
Other breast surgery
Gastric bypass
Irregular periods
Polycystic Ovarian Syndrome (PCOS)
Infertility treatment
Ever smoked
Current smoker
Fingers turn white/blue in cold
Breasts are painful in the cold
Rynaud's syndrome
Migraines
Bowel pain
Extreme pain with periods
Pain with sex
Low back pain
Cancer
Genetic concerns
Asthma
Autoimmune
Other
Medical History-other
Gastric bypass
Migraines
Bowel pain
Low back pain
Cancer
Genetic concerns
Asthma
Autoimmune
Other
Allergy/Immunology
Food sensitivities
Seasonal allergies
Yeast infections
Hepatitis
HIV
Endocrine Health
Diabetes
Hyperthyroidism
Hypothyroidism
Other thyroid problems
Irregular periods
Polycystic Ovarian Syndrome (PCOS)
Infertility treatment
Fingers turn white/blue in cold
Breasts are painful in the cold
Rynaud's syndrome
Other
Psychiatric Health
Panic attacks
Depression
Post-Partum Depression
Anxiety disorder
On anti-depressant medication
On other type of psychiatric medication
Suicidal thought
Alcohol or drug dependance
Other:
Smoking history
Yes
No
Used to smoke
Clear selection
What birth control method are you currently using?
Your answer
Are you allergic to any medications?
Yes
No
Clear selection
List the medications you are allergic to
Your answer
Are you taking any medications or supplements?
Yes
Maybe
No
Clear selection
List any supplements you are taking
Your answer
Please list other medical issues or hospitalizations
Your answer
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