Lactation Intake Form
Please fill out the intake form so you can have a more comprehensive appointment.
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Child's First Name *
Child's Last Name *
Child's Date of Birth *
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Child's Age Today *
Birth Weight *
Discharge Weight *
What issues or concerns would you like to address in today's visit? *
Discharge Date *
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Number of Wet Diapers in the Past 24 Hours
Number of Stools in the Past 24 Hours *
Number of Feedings in the Past 24 Hours *
Does your child use a pacifier?  If yes, which brand?   *
Do you have any feeding concerns such as tongue tie or lip tie?  If yes, please describe below.   *
Are you giving your baby formula?  If yes, which brand and how much are you giving him/her?   *
Has your baby been fed with a bottle?  If yes, which brand and how often?   *
Mother's Full Name *
Mother's Date of Birth *
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Do you have any previous health or medical conditions?  If yes, please describe below.   *
Are you currently taking any medications?  If yes, please list the medications below.   *
Have you had a previous breast surgery?  If yes, please list the type of surgery.   *
Were there any complications during the birth of your child?  If yes, please describe below.     *
Was your delivery vaginal or c-section? *
What was the gestational age at birth (in weeks)? *
Is this your first baby?   *
Did you see a lactation specialist in the hospital/birthing center?   *
Are you currently pumping or hand expressing?  If yes, which method?  How often and how much are you pumping/hand expressing?  And, how long do you typically pump/hand express for?     *
Are you using a nipple shield?  If yes, do you find it helpful?   *
When nursing your baby, which position(s) do you prefer?   *
Do you have plans to return to employment? *
If returning to employment? Who will care for baby? If not applicable enter "N/A." *
What are your breastfeeding goals?   *
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