Prenatal Intake Form
Please provide the following information to the best of your knowledge. We'll go over it all when we meet!
Thanks,
Erica Charpentier, IBCLC
Expectant parent's first and last name
Your answer
Consult date
MM
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DD
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YYYY
Expectant parent's date of birth
MM
/
DD
/
YYYY
Due date
MM
/
DD
/
YYYY
Expectant parent's address
Your answer
Expectant parent's phone number
Your answer
Expectant parent's email address
Your answer
Partner's first and last name
Your answer
Partner's phone number
Your answer
Midwife or OB's name and practice
Your answer
Midwife or OB's phone number
Your answer
Pediatrician's name and practice (if known)
Your answer
Pediatrician's phone number (if known)
Your answer
What is your occupation?
Your answer
If you are returning to work outside the home after giving birth, when will you return?
Your answer
Any history of:
What medications are you currently taking? (including herbs and vitamins)
Your answer
Do you plan on consuming any form of placenta?
Have you ever had a breast or chest surgery or injury? If yes, please describe in "other," including the approximate date.
Did you conceive easily?
Did you conceive with any of the following:
Do you have a history of miscarriages?
If yes, was a reason determined?
Your answer
Including your current pregnancy, how many times have you been pregnant?
Your answer
How many other children have you breastfed?
Your answer
How long have your other child(ren) breastfed?
Your answer
How did breastfeeding go with your older child(ren)?
Your answer
During this pregnancy, have you experienced any of these breast changes?
Have you ever been on bed rest? If so, please describe in "other".
Any complications during your pregnancy?
Your answer
Are you pregnant with multiples?
Where do you plan on delivering?
Your answer
Do you have a doula?
Do you have a birth plan? Include any methods (Bradley, hypnobirthing, etc.)
Your answer
Will you be having a scheduled C-section birth?
If you have given birth before, please describe your experience.
Your answer
If you have read any breastfeeding books or resources, please list them here.
Your answer
If you have prior breastfeeding experience, please describe here.
Your answer
If you experienced any unusual breast development in puberty, please describe here.
Your answer
Do you plan on having your baby circumcised? If so, please indicate the day of circumcision.
Your answer
If you have a pump, what brand of pump and what flange size (imprinted on side of flange)?
Your answer
Is your pump owned or rented?
If owned, is it a new pump, or used before with another child?
Where do you plan on your baby sleeping?
For how long do you see yourself breastfeeding?
Your answer
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