Lactation Intake Form Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Baby's Name * Baby's Due Date * MM DD YYYY Baby's Actual Birth Date MM DD YYYY Baby's Birth Weight What did baby weigh most recently and what was the date? Baby's Pediatrician Your OBGYN/Midwife Location of Birth specific hospital, home, birth center Please share details about your birth. What gestation were you when you had baby? Spontaneous or induction? Vaginal or cesarean? Any interventions or complications? What medications or supplements are you currently taking? Does your baby currently take any medications or supplements? This does not include formula. Have you ever had any breast surgeries? Yes No Have you had any injury to your breast, chest, or spine? Yes No Do you smoke cigarettes? Yes No Do you use any forms of tabacco? E-cigarettes/vaping? Yes No Do you currently smoke marijuana or use any marijuana products? Yes No Are you currently taking anything to increase your milk supply? If yes, what? Have you ever had your thyroid checked? If so, was it normal or abnormal? Has your baby been diagnosed with any medical issues or complications? Yes No Briefly describe your feeding journey up to this point. Which best describes how you feel about breastfreeding? Mostly good Hard, but worth it Contemplating ending the breastfeeding journey Do you have any breastfeeding goals you would like to share? What are your current issues/concerns and how long have they been going on? Are you experiencing any pain while feeding? If yes, please describe. How long does a nursing session usually last? Do you feed from one breast of both at each feeding? Describe any current bottle use/supplementing. Does your baby have fussy times? Does your baby have content times? How would you describe your breastfeeding relationship? Feeding on demand Feeding on a schedule About how many wet diapers does your baby have a day? in a 24 hour period About how many poop diapers does your baby have a day? in a 24 hour period What is the color/consistency of the poop? About how many times does your baby nurse at the breast within a 24 hour period? About how many times does your baby get a bottle in a 24 hour period? Does your baby still wake at night to feed? How often? Have. you done any sleep training with your baby? If so, please describe the method and how old your baby was when you started. If you are using hand expression or a breast pump to collect milk, how much are. you collecting? When are you collecting it? Are there any specific questions or concerns you'd like to touch on at our appointment that weren't already shared? Thank you!
