The Lactation Lady, LLC Intake Record Form
Today's Date
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Mother's name
Your answer
Mother's Date of Birth
MM
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Name of Obstetrician/Midwife?
Your answer
Telephone Number for Obstetrician/Midwife?
Your answer
Infant's Name
Your answer
Infant's Date of Birth
MM
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DD
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YYYY
Name of Pediatrician?
Your answer
Telephone Number for Pediatrician?
Your answer
What is your breastfeeding goal?
Your answer
What is your primary concern?
Are you facing any challenges/booby traps? Is there a medical concern? What do you have questions about?
Your answer
Family History
Please check all that apply
Allergies to Foods
Environmental Allergies
Asthma
Eczema
Breast Cancer
Diabetes
Genetic Diseases
Thyroid
Auto-immune
Any other family medical history I should be aware of?
Your answer
What age were you when you had your first menstrual period?
Your answer
Menstrual Periods Regular? or Irregular?
Regular
Irregular
Clear selection
Have you ever used birth control
Yes
No
Clear selection
If so, what kind of birth control did you use, how long and when did you stop?
Your answer
Is this your first pregnancy?
Yes
No
Clear selection
Did you ever experience a miscarriage, abortion, or infant death? When?
Your answer
Do you have other children? How many and how old?
Your answer
If you have other children, did you breastfeed them? and for how long (months)?
Your answer
If you did breastfeed other children, did you have any issues?
Your answer
Do you plan on using any of the following family planning methods while breastfeeding?
check any that you may be interested in using
None
Natural Family Planning, Rhythm Method
Birth Control Pills
Condoms
Other Barrier Methods
Tubal Ligation/ Tubes Tied
Implants/IUDs
Vasectomy
Where you ever treated for infertility issues? If so, please provide as much information as possible.
Your answer
Do you plan on returning to work or school?
Yes
No
Clear selection
If so, when will you be returning?
Your answer
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?
Your answer
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?
Your answer
Do you take any medications currently?
This includes any supplements or vitamins.
Your answer
Are there any medications that you took prior to pregnancy that you plan on reintroducing?
Your answer
Any past surgical history?
This includes Breast Surgeries, Augmentations or Reductions, and Biopsies.
Your answer
Any information about your pregnancy that I should be aware of?
Anything unusual? Gestational Diabetes? Gestation Hypertension?
Your answer
Did you notice breast changes during your pregnancy?
Yes
No
Clear selection
Any information about the delivery I should be aware of?
Induction? If so, why?
Your answer
Method of Delivery?
Vaginal
Cesarean
Clear selection
If you had a Cesarean Delivery, why?
Planned? Failure to Progress? Emergency?
Your answer
Did you experience any postpartum complications? If so, please be specific.
Your answer
Did your baby experience any post part complications? If so please be specific.
Your answer
Does your baby have any medical problems?
Your answer
Is your baby taking any medications?
Your answer
Did you get to nurse your baby after the delivery,within the first hour?
Yes
No
Clear selection
If you did not get to nurse your baby after the delivery, why?
Your answer
Tell me about your breastfeeding experience so far.
Your answer
When did you first realize you were experiencing breastfeeding difficulties?
Your answer
Do you have a breast pump? If so, what kind?
Your answer
Have you had to use your pump? If so, when and why?
Your answer
Are you using any other breastfeeding supplies?
For example, a nipple shield, breast cream, gel pads, breast shells, etc?
Your answer
If you are using breastfeeding supplies, when did you introduce them and why?
Your answer
How many times in the last 24 hours have you fed the baby at the breast?
Your answer
When feeding at the breast, does your baby typically__________
Feeds only on one side
Feeds on both breasts
Sometimes does one, sometimes does both
Clear selection
Does your baby appear content after feeding?
Yes
No
Clear selection
Have you had to use any supplements to feed your baby?
Expressed breastmilk, donor milk or formula?
Yes
No
Clear selection
If yes, what are you using?
Expressed breastmilk, donor milk or formula?
Your answer
If you are supplementing, can you please provide more information?
When are you supplementing, why, what is the current plan?
Your answer
If supplements are used, how often in the last 24 hours and how much? How much per feeding?
Be as specific as possible.
Your answer
Are you using a pacifier?
Yes
No
Clear selection
How many wet diapers has your baby had in the last 24 hours?
Your answer
How many stools/bowl movements has the baby had in the last 24 hours? and what is the color of the stool?
Your answer
Is there anything else you think I should know prior to our assessment?
Are there any other questions or concerns?
Your answer
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