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