Boston Area Lactation Connection Prenatal Questionnaire
Email *
Prenatal appointments are $200. In-home consults are $300 total with an additional $25 travel fee for locations farther than 25 miles from Red Rock Park in Lynn. Non-refundable $50 deposit is due upon completion of this intake to hold your spot. Please send to @KiraKimIBCLC on venmo or Via PayPal at www.paypal.me/nsbs. Remainder due at the time of service. Please initial below to verify that you understand this payment agreement. *
Please choose which option you would like to sign up for. "On call" is for people who are pregnant and would like to set up an in person appointment once baby is here. Choosing "On call" means that you will get priority for an appointment during the 10 day window around your due date. *
Required
Interns are an important part of The BALC practice. In order to train the next generation of IBCLCs, interns regularly attend consults alongside Kira. All interns are fully vaccinated and sign confidentiality agreements. Are you ok with an intern attending your consult? *
Name (Last, First, Middle) *
Pronouns (she/he/they) *
Parents Date of Birth *
MM
/
DD
/
YYYY
Address *
Primary Insurance (for reimbursement forms). Please note that Aetna and United Healthcare do not typically reimburse. If you have Aetna, please let me know so I can give you options. *
Baby's Date of Birth (or Estimated Due Date) *
MM
/
DD
/
YYYY
Place of Birth (Hospital name or home) *
Medical History
Age at first period? (Approximate if unsure) *
Were your periods regular before becoming pregnant (meaning relatively even cycles regardless of length): *
Do you have a history of any of the following conditions? *
Required
Do you have a personal or family history of breast cancer?
Clear selection
Do you have a family or personal history (both parents) of orthodontia, speech impediments or gaps between the front teeth?
Clear selection
Do you have or have you been told you have any abnormalities to your breasts? Marked difference in size (A vs C cup for example), tubular shape, very wide spacing, etc. *
Have you ever had surgery on your breasts (biopsy, implants, breast lift, breast reduction, lumpectomy?) -If so, please explain the procedure, how long ago it was and the reason it was performed *
Have you ever sustained an injury to your ribs or spine? *
List any current medications (include supplements, herbs, and over the counter medications)?
Pregnancy and Prior Breastfeeding Questions
How many pregnancies have you had? *
How many live births have you had (over 24 weeks)?
How old are your other children?
Was this child conceived through assisted reproductive technology (including but not limited to IUI, IVF, etc)
Clear selection
Have your breasts changed in any of the following ways during this pregnancy? *
Required
Have you breastfed before? *
If you have breastfed before, did you experience difficulties with any of the following:
Describe in detail any issues during previous breastfeeding relationships.
What are your goals for breastfeeding (duration, exclusive breastfeeding, mixed feeding, weaning to formula after a certain time period, etc?) *
Do you have any particular concerns that you would like to address? *
Submit
Never submit passwords through Google Forms.
This form was created inside of North Shore Birth Services. Report Abuse