Postpartum 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
General Information
Breastfeeding parent's first and last name
Your answer
Consult date
MM
/
DD
/
YYYY
Breastfeeding parent's date of birth
MM
/
DD
/
YYYY
Infant's name
Your answer
Infant's birth date
MM
/
DD
/
YYYY
Breastfeeding parent's address
Your answer
Breastfeeding parent's phone number
Your answer
Breastfeeding 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
Your answer
Pediatrician's phone number
Your answer
Today's visit
Current concern:
Others consulted about this concern:
Background Information
This may seem like an overwhelming number of questions, but every bit of information can help us figure out what's preventing breastfeeding from going smoothly.
Any history of:
What medications are you currently taking? (including herbs and vitamins)
Your answer
Are you consuming or have you consumed any form of placenta? If yes, please describe in "other".
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
How many other children (not this infant) do you have?
Your answer
How many other children (not this infant) 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
Your most recent pregnancy, labor, and delivery
During this pregnancy, did you experience any of these breast changes?
Were you ever on bed rest? If so, please describe in "other".
Any complications during your pregnancy?
Your answer
How would you describe your vaginal bleeding now:
How many weeks and days long was your pregnancy?
Your answer
How did labor begin?
If induced, which of the following did you use?
Where did you deliver? (Please give the name of the facility, or indicate "home".)
Your answer
How many hours was your labor?
Your answer
How many minutes were spent pushing?
Your answer
Was your delivery...
Medications during labor?
Antibiotics during labor?
If so, why?
Hemorrhage?
Please describe your labor experience.
Your answer
Your nursing experience in the hospital or birth center
How many minutes/hours after birth did you first nurse your baby?
Your answer
Was the initial nursing session...
Did you nurse on...
When did you notice your milk "come in" (aka, begin transitioning to mature milk and increasing in volume)?
How frequently did you nurse on day 1?
How frequently did you nurse on day 2?
How frequently did you nurse on day 3?
Is your baby circumcised? If so, please indicate the day of circumcision.
Your answer
Does your baby use a pacifier? If so, please indicate the day of introduction.
Your answer
Were you and your baby separated in the hospital?
What was your inpatient breast/chestfeeding experience like?
Your answer
Your nursing experience at home
Now that you are home, how often are you nursing?
How would you describe latching?
Who ends feeding sessions?
What's the average length of a feeding?
Is that for both sides, or one?
Nipple pain?
Which side?
When did it begin?
MM
/
DD
/
YYYY
Please describe your at-home breastfeeding experience.
Your answer
Where does your baby sleep?
Swaddled?
If you're supplementing...
Are you supplementing with anything?
If so, when did you begin?
MM
/
DD
/
YYYY
How are you supplementing?
When are you supplementing?
How often are you supplementing? If not at every feed, please indicate # of times a day under "other".
How much does the baby take at a time? (in oz or cc)
Your answer
If you're pumping...
Are you pumping?
If so, when did you begin?
MM
/
DD
/
YYYY
How many times/day do you pump?
On average, how much do you yield per pumping session? (from both breasts, in oz)
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?
Baby information
Baby's birth weight (lbs-oz):
Your answer
Baby's discharge weight (lbs-oz) and discharge age:
Your answer
Please enter the date, location, and amounts of your baby's weight history (eg 1/10/18, pediatrician's office, 6 lbs 4 oz)
Your answer
Diaper output - last 24 hours: urine
How many heavily soaked diapers?
Your answer
Diaper output - last 24 hours: stool
Diaper output - last 25 - 48 hours: urine
How many heavily soaked diapers?
Your answer
Diaper output - last 25 - 48 hours: stool
Diaper output - last 49 - 72 hours: urine
How many heavily soaked diapers?
Your answer
Diaper output - last 49 - 72 hours: stool
Looking ahead
If you are returning to work outside the home, when will you return?
MM
/
DD
/
YYYY
For how long do you see yourself breastfeeding?
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Erica Charpentier, IBCLC. Report Abuse