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Lactation Consultation Intake Form
Please complete entire intake form prior to appointment.
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Breastfeeding Parent Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Partner's Name
Your answer
Baby's Name
Your answer
Baby's Date of Birth
MM
/
DD
/
YYYY
Weeks Gestation
Your answer
Phone Number
Your answer
Address
Your answer
E-mail
Your answer
How did you find my services?
Your answer
Birth Weight
Your answer
Discharge/Lowest Weight and Date
Your answer
Most Recent Weight and Date
Your answer
Place of Birth, Name of Health Care Provider that Attended Birth
Your answer
Baby is Child Number
Your answer
Type of Birth, Choose All That Apply
Vaginal Birth, Unmedicated
Vaginal Birth, Medicated
Induction
Cesarean Birth
Other:
Did baby spend time in NICU? If so, how long?
Your answer
If you have breastfed a previous child, please describe experience
Your answer
Describe current challenges and current breastfeeding goals
Your answer
Current medications, supplements, vitamins. Including OTC drugs.
Your answer
Medical Conditions
Polycystic Ovarian Syndrome
Anemia
Major blood loss in labor/delivery/postpartum
Thyroid Disorder
Previous Breast Surgery
Diabetes
Infertility
Hypertension
Food Allergies or family history of allergies
Depression or Anxiety
None
Other:
Any difficulty with fertility, describe
Your answer
Did you experience breast changes in pregnancy?
Yes
No
Maybe
Clear selection
How often has your baby nursed at the breast in the past 24 hours?
No nursing at the breast
Less than 8 times
8 or more times
More than 12 times
Clear selection
Are you currently supplementing with formula? If so, how much in 24 hours?
Your answer
Are you currently pumping? If so, how often and how much are you expressing?
Your answer
When do you think your mature milk came in? (Felt engorged)
Your answer
How many urine and stool diapers in 24 hours?
Your answer
Do you typically feed on one or both breasts at every feeding?
Your answer
Are you having difficulty getting baby to latch?
Yes
No
Sometimes
Clear selection
Are you having pain when nursing?
Start of a feed
Entire feed
Nipples sore but not cracked
Nipples sore, cracked, bleeding
No pain
Are you using a pacifier? How often?
Your answer
Are you using a bottle? How often?
Your answer
Is there anything else you think should be known about your situation prior to your consult?
Your answer
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