Lactation Consultation Questionnaire

Joshua Johannson M.D., FACOG - Obstetrics and Gynecology
Mother's Name
Mother's DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mother's Occupation
Father's Name
Father's DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Father's Occupation
Infant's Name
Infant's DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Infant's Physician
What was YOUR weight before pregnancy?
Final weight you gained
How did your labor start?
Where did you receive your prenatal care?
How many pregnancies have you had?
How many births?
Birth Weight
Discharge Weight
Lowest Weight
Date of Lowest Weight

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Birth Place
Gestational Age at Birth
Type of Delivery
Baby gender
How Long Were You in Labor? (hrs)
Pushing time
Apgar's
Does your baby have any known health problems
If yes, explain
Is your baby currently on any medications?
If yes, list medications
Are YOU taking any of the following? (Please check all that apply)
Others
How many days after birth did your milk come in?
In the last 24 hours, how many times have you breastfed baby?
In the last 24 hours, how many wet diapers?
Stools?
Is stool larger than table spoon?
What color is stool?
How often does baby have explosive stools? Always/ sometimes/ never/ rarely
How often does your baby spit- up? Always/ sometimes/ never/ rarely
Is baby being supplemented? Nothing/ water/ formula/ own pumped milk/ milk bank
If yes, what type of supplementer? Spoon/ cup/ bottle/ syringe/ supplemental nursing system
How much is baby in- taking?
How often?
Have you used any of the following? (If yes, circle)
Electric Pump Type
Are you using a pacifier?
If so, approximately how many hours per day?
Did you notice breast changes during pregnancy?
If yes, explain
Have you ever had breast surgery?
If yes, explain
Have you had prior breast feeding experience before?
ages at weaning
Who initiated weaning?
Any past breastfeeding issues?
If yes, explain
Do you breastfeed/ pump/ bottle formula/ or a mixture?
Has baby had:
How often do you pump?
How often does baby get formula?
What type of breast pump do you use?
Standard flange?
How long does your baby nurse? (in minutes)
How many times a day?
How long is the range between the beginning of one feed to the next feeding? (in hours)
Does your baby cough or choke at the breast?
Is baby distressed at the breast?
Explain if yes for either:
Are you currently waking baby for feedings?
Does baby have difficulty latching?
How often does baby seem satisfied after feeding? Always/ sometimes/ never
How often does baby soften at least one breast during feeding? Always/ sometimes/ never
Can you hear baby swallowing during feeding?
How often do your nipples turn white during/ after feeding? Always/ sometimes/ never
Are YOU experiencing pain? _________ If no, please skip this section.
Is it painful for both breast, left breast, or right breast?
Is pain worse on one side than the other?
Which side?
When is the pain more intense? Beginning, during, or after feeding/ with pumping/all the time?
Do you have nipple pain while: breastfeeding/expressing milk/not feeding or expressing milk?
Do you have breast pain while: breastfeeding/expressing milk/not feeding or expressing milk?
If yes to the two (2) above questions, explain:
Have you used any of the following to treat nursing or pumping pain?

1. Expressing milk onto nipples after feeding or pumping
2. All- purpose nipple ointment/ Jack Newman’s Nipple Cream
3. Nipple shields
4. Nipple shell
5. Lanolin ointment
6. Changed size of Flange
7. Hydrogel dressings (Soothies)
8. Tylenol/ acetaminophen
9. Motrin/ ibuprofen
10. Heat to breast after feeding
11. Aquaphor/ Vaseline
12. Ice pack to breasts
13. Infant treated for yeast infection
14. Maternal antifungal pills (include name)
15. Maternal Cream/ointment for yeast (include name)
16. Maternal Antibiotic pills (include name)
17. Maternal cream/ ointment for bacteria (include name)
18. Steroid Cream/ ointment (include name)
If yes, specify which number, used when, a name if necessary, and if treatment/medication worked or made worse.
For each of the following BREASTFEEDING statements, please describe how confident you are (VERY, NOT, SOMETIMES)
I can always determine that baby is getting enough milk.
I can always successfully cope with breastfeeding like I have with other challenging tasks.
I can always breastfeed my baby without using formula as a supplement.
I can always ensure that my baby is properly latched on for the whole feeding..
I can always manage the breastfeeding situation to my satisfaction.
I can always manage to breastfeed even if baby is crying.
I can always keep wanting to breastfeed.
I can always breastfeed comfortably with family members present.
I can always be satisfied with my breastfeeding experience.
I can always deal with the fact that breastfeeding can be time consuming.
I can always finish feeding baby on one breast before switching to the other breast.
I can always continue to breastfeed my baby for every feeding.
I can always keep up with baby's breastfeeding demand.
I can always tell when baby is finished breastfeeding.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PEDIATRIC HISTORY FORM
Infant's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Birth Weight
Lbs
OZ
Birth Length (Inches)
Discharge Weight
Lbs
OZ
Sex
Apgars
Weeks of Gestation
Birth Place
Delivery Type
Outcome: (please check one)
Breastfeeding or Formula?
Complications
Signature of Parent
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

PEDIATRIC HISTORY FORM