The Lactation Lady, LLC Intake Record Form
Today's Date
Mother's name
Mother's Date of Birth
Name of Obstetrician/Midwife?
Telephone Number for Obstetrician/Midwife?
Infant's Name
Infant's Date of Birth
Name of Pediatrician?
Telephone Number for Pediatrician?
What is your breastfeeding goal?
What is your primary concern?
Are you facing any challenges/booby traps? Is there a medical concern? What do you have questions about?
Family History
Please check all that apply
Any other family medical history I should be aware of?
What age were you when you had your first menstrual period?
Menstrual Periods Regular? or Irregular?
Clear selection
Have you ever used birth control
Clear selection
If so, what kind of birth control did you use, how long and when did you stop?
Is this your first pregnancy?
Clear selection
Did you ever experience a miscarriage, abortion, or infant death? When?
Do you have other children? How many and how old?
If you have other children, did you breastfeed them? and for how long (months)?
If you did breastfeed other children, did you have any issues?
Do you plan on using any of the following family planning methods while breastfeeding?
check any that you may be interested in using
Where you ever treated for infertility issues? If so, please provide as much information as possible.
Do you plan on returning to work or school?
Clear selection
If so, when will you be returning?
If you will be returning to work/school and plan to continue breastfeeding and provide breastmilk, can you provide some information about your circumstances?
Full/Part Time, how long and how often will the separation be?
Maternal History; do you have any medical concerns that I should be aware of?
Thyroid Issues, Hypertension, Diabetes, PCOS, Past Breast Surgeries or Biopsies, Anxiety, Depression? Anything?
Do you take any medications currently?
This includes any supplements or vitamins.
Are there any medications that you took prior to pregnancy that you plan on reintroducing?
Any past surgical history?
This includes Breast Surgeries, Augmentations or Reductions, and Biopsies.
Any information about your pregnancy that I should be aware of?
Anything unusual? Gestational Diabetes? Gestation Hypertension?
Did you notice breast changes during your pregnancy?
Clear selection
Any information about the delivery I should be aware of?
Induction? If so, why?
Method of Delivery?
Clear selection
If you had a Cesarean Delivery, why?
Planned? Failure to Progress? Emergency?
Did you experience any postpartum complications? If so, please be specific.
Did your baby experience any post part complications? If so please be specific.
Does your baby have any medical problems?
Is your baby taking any medications?
Did you get to nurse your baby after the delivery,within the first hour?
Clear selection
If you did not get to nurse your baby after the delivery, why?
Tell me about your breastfeeding experience so far.
When did you first realize you were experiencing breastfeeding difficulties?
Do you have a breast pump? If so, what kind?
Have you had to use your pump? If so, when and why?
Are you using any other breastfeeding supplies?
For example, a nipple shield, breast cream, gel pads, breast shells, etc?
If you are using breastfeeding supplies, when did you introduce them and why?
How many times in the last 24 hours have you fed the baby at the breast?
When feeding at the breast, does your baby typically__________
Clear selection
Does your baby appear content after feeding?
Clear selection
Have you had to use any supplements to feed your baby?
Expressed breastmilk, donor milk or formula?
Clear selection
If yes, what are you using?
Expressed breastmilk, donor milk or formula?
If you are supplementing, can you please provide more information?
When are you supplementing, why, what is the current plan?
If supplements are used, how often in the last 24 hours and how much? How much per feeding?
Be as specific as possible.
Are you using a pacifier?
Clear selection
How many wet diapers has your baby had in the last 24 hours?
How many stools/bowl movements has the baby had in the last 24 hours? and what is the color of the stool?
Is there anything else you think I should know prior to our assessment?
Are there any other questions or concerns?
Never submit passwords through Google Forms.
This form was created inside of The Lactation Lady, LLC.