Lactation Consult Intake Form
Before your appointment, please complete this intake form.  Thank You!  Feel free to contact me for any questions at 617-501-4451 or breastfeednh@gmail.com.
Sign in to Google to save your progress. Learn more
Your name (mom): *
Date of birth (mom): *
MM
/
DD
/
YYYY
Phone number you can be reached at and/or email:
Health History:  ex diabetes, PCOS, breast surgery, thyroid condition, etc. *
List all medications, herbs or vitamins that you are currently taking:
Do you follow a specific diet?  ex: vegetarian
Who is your OBGYN MD? *
What hospital did you deliver at?
Delivery Method: *
Baby's gestational age at birth? *
Was there any complications after delivery? *
Do you have other children?   *
If so, how did breastfeeding go with each of your other children?  Was there any issues/concerns? ex low milk supply, etc
What are your breastfeeding/feeding goals for your baby? *
Reason for lactation consultation: *
What breast pumps do your currently own? *
Baby's Name: *
Baby's Date of birth: *
MM
/
DD
/
YYYY
Pediatrician & office location: *
Baby's birthweight: *
Baby's current weight at last pediatrician visit *
How old is your baby?  *
Does your pediatrician have any concerns regarding your baby at this time? *
In the last 24 hours, how many times has your baby fed? *
In the last 24 hours, how many feedings were at breast? *
In the last 24 hours, how many feedings were pumped breastmilk via a slow flow bottle? How many ounces per feeding did the baby take? *
In the last 24 hours, how many feedings were formula via slow flow bottle? How many ounces of formula did the baby take per feeding? *
If baby is bottle feeding, what brand of bottle are you using?
In the last 24 hours, how many wet diapers has your baby had? *
In the last 24 hours, how many dirty (stool) diapers has your baby had? *
What color is your baby's stool (poop)? *
Any other information you would like to share before our appointment.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy