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:*

Breast CancerDiabetesInfertilityHypertensionThyroid IssuesPolycystic Ovarian ProblemsPast Breastfeeding SyndromeNone
Mood Issues (Includes personal and family)*

DepressionAnxietyPostpartum DepressionNone
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)

High Blood PressureShortness of BreathAbnormal Blood SugarHeadachesVisual ChangesFever or ChillsBreast PainNipple PainBreast LumpSwelling in legs/handsJoint/Back Muscle PainConcerns about your mood or emotions
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*

Spouse/PartnerChildrenParentsOther
Work outside the home?*

Full-TimePart-TimeNo
Occupation?
Date Returning to Work:

MonthDayYear
OTHER THINGS WE SHOULD KNOW ABOUT?
Marital Status:*

SingleMarried
Do you Smoke?*

YesNo
Any household members smoke?*

YesNo
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:*

YesNo
Jaundice:*

YesNo
Reflux:*

YesNo
Surgeries:*

YesNo
Hospital Readmission:*

YesNo
NICU Stay:*

YesNo
Other:*

YesNo
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