CLIENT INTAKE FOR PRENATAL CONSULT
Prenatal History
Expectant mother's name: *
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Please provide best day(s) and time(s) for you to have this visit.
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Partner's name:
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Expectant mother's date of birth: *
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Address (street, city and zip code please) *
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Please describe parking in your neighborhood. Note: client is responsible for any parking fees.
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Mobile phone *
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Email *
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Insurance company. *Please note: Chicago Lactation Consultants is not an "in-network" provider for any insurance company. We will provide you with a claim to submit for reimbursement but we cannot guarantee full reimbursement. You may want to contact your insurance carrier in advance to understand your benefits. Laura is available for questions at 312 320 3996.
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How did you find us? Check all that apply
Due date *
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What is your occupation?
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Will you be returning to work? When? Part or full-time?
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How many times have you been pregnant?
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How many children do you currently have, and their ages.
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How many babies in this pregnancy?
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Where will you be delivering?
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Who is your birth provider?
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Do you have a doula? Check all that apply
Do you have a birth plan? Include any methods (Bradley, hypnobirthing, etc.)
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Is this a planned C-section?
If you have given birth before, please describe your experience here.
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Did or will you take a breastfeeding class?
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If you have read any breastfeeding books or resources, please list here.
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If you have prior breastfeeding experience, please describe here.
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If you had any fertility issues, please describe here.
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If any unusual breast development in puberty, please describe here.
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If any breast surgeries or injuries or nipple piercings, please describe here, including approximate dates.
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Any health issues?
Are you on any medications? Please include condition(s).
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Did you have breast growth or other breast changes in pregnancy?
Have you seen positive breastfeeding experiences?
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Do you feel you have adequate support for breastfeeding?
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What is your breastfeeding goal?
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Have you used any holistic modalities in your health care?
Are you interested in learning more holistic means to improve health?
Anything you would like to add? Fears/concerns, specific questions, would like pump suggestions, etc.
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I look forward to working with you!
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