Lactating Dyad Health Intake Form
Confidential Client Intake Record
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Client's First and Last Name *
Partner/Relationship *
Client's DOB *
MM
/
DD
/
YYYY
Phone number *
Address *
Email address *
Birth Care Provider
Feeding Goals *
Occupation? Returning to Work   *
Do you feel safe in your home?
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Have you had any of the following health concerns? *
Current medications, pain killers, supplements, herbs: *
Allergies *
Number of Pregnancies *
Number of Children *
Any infertility issues? *
Have you had any breast surgeries/biopsies or trauma? *
Other surgeries?
Current Birth Control Method *
Dietary restrictions: *
Have you eaten any candies/teas/foods with Peppermint? *
Do you have a history of depression? *
Have you been on medication for it? If yes, what medications?
Currently, how is your mood? *
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