New Patient Intake Form

Love in Leche New Patient Intake and Consent Form
Mother's Name*

First NameMiddle NameLast Name
Mother's Date of Birth*

MonthDayYear
Infant's Name*

First NameMiddle NameLast Name
Infant's Date of Birth or Due Date*

MonthDayYear
Infant's Birth Weight*
Infant's gestational age at birth (ex: 40 wk 3d)*
Infant's Sex*
Location of birth *
2nd Infant's Name (if multiples)

First NameMiddle NameLast Name
2nd Infant's Birth Weight
2nd Infant's Sex
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
Preferred Phone*

Area CodePhone Number
Alternate Phone

Area CodePhone Number
Marital Status:*

SingleMarriedDivorcedWidowedSeparatedDomestic Partner
Partner's Name
Partner's Date of Birth

MonthDayYear
Partner's Phone

Area CodePhone Number
Do you want your partner to be your emergency contact?*

YesNo (please list alternate below)
Emergency contact

First NameLast Name
Emergency contact phone

Area CodePhone Number
Return to Work Date

MonthDayYear
Maternal Work Status*

EmployedStay at HomeDisabled fom workWill return to part time workWill return to full time work
Occupation
Employer
I was referred to this practice by:*
OBGYN/Midwife Name*
OBGYN/Midwife Phone Number

Area CodePhone Number
OBGYN/Midwife Fax Number

Area CodePhone Number
Doula Name
Doula Phone Number

Area CodePhone Number
Pediatric Primary Care Provider (PCP)*
Infant PCP Phone Number

Area CodePhone Number
PCP Fax Number

Area CodePhone Number
Medical History
Have you or anyone in your household been exposed to or tested positive for COVID-19?*

YesNoPossiblyOther
If yes, please explain:
In your own words describe any feeding-related problems that concern you:*
Maternal Health History. Do you have any of the following past or present?*

food allergies/environmental allergiespolycystic ovarian syndromeanemiadiarrhea (chronic)constipationheart diseasediabeteshepatitisvenereal diseasehemorrhoidsthyroid disordercancerblood pressure issuesliver/gallbladder issuestuberculosisyeast infectionsabuseasthmaeating disorderkidney/bladder issuesautoimmune conditioncardiac/respiratory issuesfertility issues/trouble conceivingabnormal pap smeardigestive issuespregnancy loss (abortion, miscarriage, etc)surgeryherpesIVF/IUI conceptionvegan dietvegetarian dietalcohol usetobacco usedrug usemood disorders (depression, anxiety, bipolar, etc)currently being abused and/or feel unsafe in the homeOther
Bra size before pregnancy:*
Bra size now:*
Please list any breast-related issues that apply to you:*

breast implantsbreast reduction surgerybreast/nipple biopsynipple piercingsherpes on the nipplehistory of chest tubemastitissevere engorgmentcracked/bleeding nipplesmilk supply concernssore nipples with feedings.thrush/yeast of the nipplenone or minimal breast changes in pregnancy/postpartumno breast-related concerns to reportOther
Please list any other maternal health, hormonal, dietary, or breast issues you wish to share:
Are you taking any of the following?

prenatal vitamin-mineralironantihistaminecold remediesantibioticsaspirinlaxativeswater pillsantacidsbirth control pillspain pillsdiet pillsherbsOther
Are you using anything topical on your nipples right now? If yes, what?
What is your current form or future method of birth control? When did or will you start it?
Do you have any physical challenges or limitations we should know about?
Family Health History. Does the baby's father or your family have any of the following?*

genetic issuesankyloglossia (tongue tie)allergiesthyroid disordersautoimmune issuesalcoholismn/aOther
List any other family health issues:
Number of pregnancies you have had:*
Number of live births you have had:*
Number of infant losses (miscarriage or elective termination) you have had:*
Most recent pregnancy history. Did you experience any of the following?*

preterm laborblood pressure issuesblood sugar issuesgestational diabetessevere nauseaurinary tract infectioninfection/feverassisted conceptionmedicationsno concerns to reportOther
List any other pregnancy issues:
Birth History. Did you experience any of the following:*

induction (rupture of membranes, pitocin, etc)pain meds (epidural, narcotics, etc)blood pressure concernsfever/infectiongroup B strep positivehemorrhage/excessive bleedingepisiotomy/tearingtotal labor longer than 30 hourspushing stage longer than 2 hoursbreech position of babyvaginal deliveryvacuum or forceps assistedcesarean delivery (planned or emergency)retained placenta requiring ultrasound and/or removalantibiotics neededOther
Any postpartum complications?*

urinary/other infectionslow blood pressurehigh blood pressureexcessive bleeding or hemorrhagingn/aOther
List any other birth issues:
Infant Health History. List any issues past or present:*

blood sugar issuesjaundicemeconium aspirationrespiratory issuesmedical/congential condtitionknown tongue or lip tieknown cleft palate or lipyeast/thrushfussy baby/colicky babyhigh hematocritdigestive issues (reflux, spit up, stool concerns, etc)no issues to reportOther
List any other infant issues:
If a tongue and/or lip tie was released, please list the date of the procedure and the provider that performed the surgery:
How old was your baby when you first realized you were having breastfeeding issues?*
Feeding history. Please check all that apply:*

Baby is exclusively breastfed.Baby needed supplementation early on but not now.Baby currently needs supplementation.Baby does not latch at all.Baby had preference for one breast.Baby not interested.Baby crying excessively.Baby always seems hungry.Baby will latch but is inefficient, sleepy or causes pain.Baby gets supplemented at breast (SNS, tube, etc).Baby gets supplement via finger feeding.Baby gets donor milk or expressed breastmilk.Baby gets formula.Mother uses a nipple shield.Baby gets a pacifier.Baby gets a bottle.Baby takes solids.Mother is pumping.Other
How many times in the past 24 hours have you breastfeed your baby?*

less than 6 timesless than 8 times8-10 timesmore than 12 times
What is the longest time your baby has gone between feedings? Day*
Night*
Is the baby content or sleeping in between feedings?*

neveroccasionallyoften
Who decides the feeding is over?*

MotherBaby
How long does the baby nurse left side?*
Right side?*
Please describe anything else about the feeding routine that you would like us to know:
How many months do you wish to breastfeed your baby?*

1 month2-3 months3-6 months6-9 months12 monthslonger than 12 monthsOther
If the infant is supplemented, please list what type of supplementation and what amounts are used per feeding/per day. What brand bottle or supplementer is used?
List any medications, vitamins or herbs the infant gets:
If mother is pumping, please list what type of pump is used, how often pumping occurs and how much milk is yielded per pumping session.
Please list names, dates of birth of any other children. If you breastfed them, did you have any issues? If yes, please explain:
Tell me about your infant's digestion (how many wet/dirty diapers per day? Color? Spit-up? Additional notes?):*
Tell me about your mood. Are you feeling anxious, sad, depressed, angry, overwhelmed, etc?
Is there anything else you want the lactation consultant to know?
Consent and Release of Information
Consent Agreement to read and signed before the consultation

* I understand the following: The lactation consultant is an allied health care provider and responsible for evaluating and recommending a care path to resolve or improve breastfeeding issues. A lactation visit includes a detailed history of mother/infant, an assessment of maternal/infant anatomy, observation of a feeding for evaluation of technique and effectiveness of feeding, and recommendations for management to improve and/or resolve breastfeeding related issues. All clients are provided with a written and/or oral care path to improve breastfeeding concerns. The client and the lactation consultant each have responsibilities in this path. Resolution of a breastfeeding problem often takes several days or weeks and may require a change in the original recommended care path at some point.

* I understand that I am responsible for informing the lactation consultant of changes I feel are necessary in the care path at the time of the visit or during the course of follow-up communications. Phone contact during the time following the lactation visit is crucial and considered an extension of your visit. You will be given a phone number to call to report progress or to communicate continued problems or concerns. I understand it is my responsibility to contact the lactation consultant with progress reports, questions or concerns.

* I understand any change from my physician’s recommendations should be discussed with the physician. Health care issues of a medical nature MUST be discussed with a physician.

* I understand a partial or follow-up visit is sometimes necessary. I understand that breastfeeding supplies and/or breast pumps may be recommended as effective management of specific situations. Only effective equipment will be recommended. If a client chooses to utilize any equipment, supplies or nutritional supplements risks and benefits will be discussed but the client is responsible for choosing whether or not to use these items and for any associated outcomes.

* I hereby authorize the lactation consultant to release any information acquired in the evaluation and/or management of myself and/or my child to our health care providers, referring physician, referring lay breastfeeding counselor, and/or our insurance company upon request. I understand the lactation consultant may contact my physician or my child’s physician if the lactation consultant feels it is necessary to consult with the physician.

* I have received a copy of this provider’s HIPAA Privacy Practices or viewed them online here: LoveinLecheHIPAAForm

* I understand this practice accepts only fee for service at time of service. It is my responsibility to pursue reimbursement for lactation services from my insurance company. This practice does no billing for insurance reimbursement and is not a provider on any insurance plan. Reimbursement is not guaranteed, but filing is suggested.
I give permission for the lactation consultant to communicate with me via phone, email and/or text message in regards to my case following our visit (which are sometimes considered unsecured forms of communication). Love in Leche adheres to HIPAA privacy practices but realizes some patients may choose text and email contact for convenience at their own discretion.*

YesNo
I give permission for information, photos and/or videos of my lactation visit to be used for professional, clinical research, education and/or articles. I understand all identifying factors will be removed.*

YesNoOther
Signature - I have read the above consent and release information and agree to the terms. (Typing your name below qualifies as a digital signature)*
Date signed*

MonthDayYear
Date
Dropbox File Name - Hidden Field
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Love in Leche New Patient Intake and Consent Form

Medical History

Consent and Release of Information