New Patient Intake 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:

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?

Emergency contact

First NameLast Name

Emergency contact phone

Area CodePhone Number

Return to Work Date

MonthDayYear

Maternal Work Status

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

Have you or anyone in your household been exposed to or tested positive for COVID-19?

Other

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?

Bra size before pregnancy:

Bra size now:

Please list any breast-related issues that apply to you:

Please list any other maternal health, hormonal, dietary, or breast issues you wish to share:

Are you taking any of the following?

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?

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?

List any other pregnancy issues:

Birth History. Did you experience any of the following:

Any postpartum complications?

List any other birth issues:

Infant Health History. List any issues past or present:

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:

How many times in the past 24 hours have you breastfeed your baby?

What is the longest time your baby has gone between feedings? Day

Night

Is the baby content or sleeping in between feedings?

Who decides the feeding is over?

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?

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?

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.

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.

Other

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

Date

Dropbox File Name - Hidden Field

Love in Leche New Patient Intake Form

Medical History