Patient’s Name ____________________________________Birth date ____________________ Today’s Date _______________________

 Medical problems: ________ Heart disease ____________ Bleeding disorders _____________   Other______________________

______Male _______Female      Birth Weight ____________   Present Weight ____________ Birth Hospital__________________

_______Vaginal birth _________C-Section Birth     Any birth complications? ____________________________________________

Are you presently breastfeeding _____Yes _____No  If no, how long since you stopped breastfeeding _____________

Medical History:

1. Infants are usually given vitamin K at birth. Did your child receive the vitamin K shot?  _____yes ______no

2. Was your infant premature? ____ Yes ____ No  If yes, how many weeks? _____________

3. Does your infant have any heart disease ____ Yes ____ No  

4. Has your infant had any surgery? ____ Yes ____ No

5. Has your infant experienced any of the following? Please check / circle / elaborate as needed.

____ Shallow latch at breast or bottle

____ Falls asleep while eating

____Slides or pops on and off the nipple

____ Colic symptoms / Cries a lot

____ Reflux symptoms

____ Clicking or smacking noises when eating

____ Spits up often? Amount / Frequency_______________

____ Gagging, choking, coughing when eating

____ Gassy (toots a lot) / Fussy often  

____ Poor weight gain

____ Hiccups often

____ Lip curls under when nursing or taking bottle

_____Gumming or chewing your nipple when nursing

_____Pacifier falls out easily, doesn’t like, won’t stay in

_____ Milk dribbles out of mouth when nursing/bottle

_____ Short sleeping requiring feedings every 1-2hrs

_____Snoring, noisy breathing or mouth breathing

_____Feels like a full time job just to feed baby

_____ Nose congested often

_____ Baby is frustrated at the breast or bottle

How long does baby take to eat? ________________

How often does baby eat? ________________________

6. Is your infant taking any medications? ____ Reflux _____Thrush   Name of medication: __________________

7. Has your infant had a prior surgery to correct the tongue or lip tie? If yes, when, where, and by whom?


7. Do you have any of the following signs or symptoms? Please check / circle / elaborate as needed.

____ Creased, flattened or blanched nipples

____ Lipstick shaped nipples

____ Blistered or cut nipples

____ Bleeding nipples

Pain on a scale of 1-10 when first latching ________

Pain (1-10) during nursing: _______

____ Poor or incomplete breast drainage

 ____ Infected nipples or breasts

_____Plugged ducts / engorgement / mastitis

_____Nipple thrush

_____ Using a nipple shield

_____Baby prefers one side over other  _____ (R/L)

Pediatrician ________________________________________________________Phone number: ____________________________________

Lactation Consultant ______________________________________________Phone number:_____________________________________

Who referred you to us?  __________________________________A close up of a logo

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Parent/Guardian Signature __________________________________________ Doctor’s Signature ____________________________________________________