Lactation/Breastfeeding Consultation

Lactation and Breastfeeding Consultation Information
For your initial lactation/breastfeeding consultation, please complete this information.
Medical & Pregnancy History
Date:

MonthDayYear
Name:

First NameMILast Name
Your DOB:

MonthDayYear
Who referred you to our office?
Briefly state why you are here today?
This Birth
Where was your baby born?
Delivery Type:
Induced?
Epidural?
Any problems with your...
Pregnancy?
Labor/Delivery?
Postpartum?
Medications taken during pregnancy:
Allergies
Medication:
Food/Other:
Past and Current Medical History
Number of Pregnancies?
Any miscarriage/terminations?
Any history of the following:
Mood Issues (Includes personal and family)
Any other significant medical problems, conditions or hospitalizations?
Medications/supplements taking now:
SURGICAL HISTORY
(Please include cesarean deliveries and breast surgeries)
Date:

MonthDayYear
Surgery Type:
Date:

MonthDayYear
Surgery Type:
REVIEW OF SYMPTOMS
Any recurrent problems?
Any recurrent problems? (Check all that apply)
Other things we should know about?
FAMILY HISTORY
Your Children
Child's Name:
DOB:

MonthDayYear
Breastfed how long?
General Health:
Medications/Supplements taking now:
Child's Name:
DOB:

MonthDayYear
Breastfed how long?
General Health:
Medications/Supplements taking now:
Child's Name:
DOB:

MonthDayYear
Breastfed how long?
General Health:
Medications/Supplements taking now:
Breastfed how long?
Child's Name:
DOB:

MonthDayYear
General Health:
Medications/Supplements taking now:
FAMILY/WORK LIFE
Who lives with you? Check all that apply
Work outside the home?
Occupation?
Date Returning to Work:

MonthDayYear
OTHER THINGS WE SHOULD KNOW ABOUT?
Marital Status:
Do you Smoke?
Any household members smoke?
Baby History
Date:

MonthDayYear
Date
Baby's name:
Baby's DOB:
Briefly state why you are here today:
MEDICATIONS/SUPPLEMENTS
List any that baby is taking currently:
PREVIOUS THERAPIES
List any previous therapies/treatments received since baby's birth. (Physical Therapy, Chiropractic, Frenotomy, etc):
MEDICAL ISSUES
Low Blood Sugar:
Jaundice:
Reflux:
Surgeries:
Hospital Readmission:
NICU Stay:
Other:
BABY’S BIRTH
Due Date:

MonthDayYear
Birth Weight:
Discharge weight, if known:
Baby's lowest weight and date:
FEEDING/PUMPING HISTORY
Approximately how many times does your baby typically BREASTFEED in a 24-hour period?
Approximately how many ounces of EXPRESSED BREAST MILK does baby typically get in a 24-hour period?
Approximately how many ounces of FORMULA does baby typically get in a 24-hour period?
Approximately how many times do you typically PUMP or HAND EXPRESS in a 24-hour period?
Approximately how many total ounces you typically PUMP or HAND EXPRESS 24-hour period?
REVIEW OF SYMPTOMS
Number of wet diapers in a 24-hour period:
Number of soiled diapers in a 24-hour period:
Typical stool color:
Extra sleepy/hard to wake?
Fussy/crying a lot?
Excessive spit up?
Discomfort with spit up?
Other things we should know about?
Should be Empty:

Lactation and Breastfeeding Consultation Information

Medical & Pregnancy History

Past and Current Medical History

SURGICAL HISTORY

REVIEW OF SYMPTOMS

FAMILY HISTORY

FAMILY/WORK LIFE

OTHER THINGS WE SHOULD KNOW ABOUT?

Baby History

MEDICATIONS/SUPPLEMENTS

PREVIOUS THERAPIES

MEDICAL ISSUES

BABY’S BIRTH

FEEDING/PUMPING HISTORY

REVIEW OF SYMPTOMS