New Client Health History Form
Please complete this form the best of your ability. There are some personal questions, if you would rather tell me verbally, that is perfectly fine. Each of these questions help me have a better understanding of your breastfeeding situation. I am here to help you and the more I know, the better I am able to do that. This Google Form is HIPAA compliant and your information is kept private.

I ask for your health insurance information to include on the "ICD-10 Superbill" that I will provide to you. You can submit this to your health insurance company for reimbursement.
Your Name *
Your answer
Home Address *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Your date of birth *
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Name of health insurance provider/carrier(for you not baby, if different) *
Your answer
What is the full name of the primary (aka subscriber) for the health insurance? Probably you or your spouse.
Your answer
Insurance subscriber's date of birth
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Health insurance ID number
Your answer
Health insurance group number
Your answer
Any secondary health insurance? If so, provide details
Your answer
OB/GYN, Midwife or Primary Care Provider *
Your answer
Pediatrician *
Your answer
How did you learn about me? *
Your answer
Reason for this appointment? Any specific concerns? *
Your answer
Have your seen anyone else regarding this concern or for breastfeeding support? If so, who? Briefly explain. *
Your answer
Number of children you have given birth to? Describe any previous breastfeeding experience. *
Your answer
Your height *
Your answer
Your pre-pregnancy weight *
Your answer
Your age *
Your answer
What vitamins, supplements, herbs, or special diet are you using? *
Your answer
Do you have a history of any of the following? Check all that apply and we will discuss in more detail during your appointment. These things may not have an impact on breastfeeding. *
Required
Baby's first and last name *
Your answer
Baby's date of birth *
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Baby's location of birth (name of hospital or home) *
Your answer
Gestational age at birth *
Your answer
Birth Weight *
Your answer
Date and weight at hospital discharge *
Your answer
Last (most recent) 3 weights with dates and location (hospital, pediatrician, home) *
Your answer
Has baby ever been fed any way other than at the breast? If so, please describe when and how. for ex, bottles, dropper, finger feeding, at breast supplementer, etc. *
Your answer
During the last 24 hours, number of feedings at the breast, please describe. *
Your answer
During the last 24 hours, number of feedings with bottle. Please describe: What was in the bottle, amount in each bottle, etc? *
Your answer
In the past 24 hours, have you pumped? please describe: how many times, how long, how much milk removed? *
Your answer
In the last 24 hours, how many poopie diapers? Describe color and amount *
Your answer
In the past 24 hours, how many wet diapers? *
Your answer
Regarding your baby's birth, please mark all that apply *
Required
Any other information about you or your baby that may help me understand your situation better?
Your answer
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