Lactation Intake Form
Please fill out the intake form so you can have a more comprehensive appointment.
Child's First Name *
Your answer
Child's Last Name *
Your answer
Child's Date of Birth *
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Child's Age Today *
Your answer
Birth Weight *
Your answer
Discharge Weight *
Your answer
What issues or concerns would you like to address in today's visit?
Your answer
Discharge Date *
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Number of Wet Diapers in the Past 24 Hours
Your answer
Number of Stools in the Past 24 Hours *
Your answer
Number of Feedings in the Past 24 Hours *
Your answer
Does your child use a pacifier? If yes, which brand? *
Your answer
Do you have any feeding concerns such as tongue tie or lip tie? If yes, please describe below. *
Your answer
Are you giving your baby formula? If yes, which brand and how much are you giving him/her? *
Your answer
Has your baby been fed with a bottle? If yes, which brand and how often? *
Your answer
Mother's Full Name *
Your answer
Mother's Date of Birth *
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What is the reason for your visit? *
Your answer
Do you have any previous health or medical conditions? If yes, please describe below. *
Your answer
Are you currently taking any medications? If yes, please list the medications below. *
Your answer
Have you had a previous breast surgery? If yes, please list the type of surgery. *
Your answer
Were there any complications during the birth of your child? If yes, please describe below. *
Your answer
Was your delivery vaginal or c-section? *
What was the gestational age at birth (in weeks)? *
Your answer
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? *
Your answer
Are you using a nipple shield? If yes, do you find it helpful? *
Your answer
When nursing your baby, which position(s) do you prefer? *
Your answer
What are your breastfeeding goals? *
Your answer
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