Lactation Intake Form

Lactation Intake Form

Thank you for taking the time to complete this form! It will help me understand what's going on with you and your baby, so I can best support you in your breastfeeding journey.
Name

First NameLast Name
E-mail
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityCounty

Post Code
Preferred Language:
Please share your concerns and goals for our work together:
Baby's Date of Birth

DayMonthYear
Preferred Language:
Place & Method of Birth

HomeHospitalBirthing CenterVaginalCesareanInduced LaborSpontaneous Labor
Interventions & Medications in Labor (Pitocin/other oxytocic drugs, assisted delivery, IV fluids, pain medication, etc.)
Interventions to baby after birth (suctioning, tube-feeding, supplementation with formula or water, vaccinations, etc.)
Was baby separated from mother after birth? For how long?
Use this space to tell me anything else about your birth that feels important:
Number of previous children:
Number of previous children breastfed:
Breast/Chest Surgeries:
Returning to work? If yes, when?
Partner's Name:
Were you breastfed as a baby?*

yesno
Do you smoke?

YesNo
Dietary Restrictions:

VegetarianVeganLow FatLow CarbGluten FreeOther
Allergies or Food Intolerances:
Mother's Medications:
History of Lactation Problems:
Breast/chest surgeries (biopsies, lumpectomies, implants, reduction, top surgery, etc.)
Current or past health problems of the mother:
History of fertility treatment:
Number of days after birth that milk came in:
Baby sleeps in:

Client's bedOwn bed in client's roomOwn room
Main sources of support (partner, doula, family, friends):
How does your family feel about lactation?
How long do you wish to breastfeed?
Baby's Name:
Sex:
Birth Weight:
Birth Length:
Gestation at birth:
Current age:
Currently at:

HomeHospital
Current Weight:
Current Length:
Number of feeds in last 24 hours:
Average length of feeds:
How many times does the baby feed at night?
# of wet diapers in last 24 hours:
# of dirty diapers in last 24 hours:
Color & condition of dirty diapers (yellow, green, brown, pasty, frothy, mucus-y, etc.)
Baby feeds from both sides or one side?
Who decides when it's time to stop nursing, mother or baby?
Check all that apply:

Exclusively breastfeedingCombination of breast & bottleExpressed milkDonor MilkSome formulaFully formula feeding
Average length lactation:
Does the baby have:

FormulaJuiceWaterSolidsOther
Amount of each:
Has the baby been given a pacifier?

yesno
Current or past health problems in the baby:
Baby's medications, if any:
How comfortable were your breasts when your milk came in?

1

2

3

4

5

6

7

8

9

10

1 is Painful, 10 is Comfortable
Have you used a pump at all? If yes, how often are you pumping?
Are you experiencing any postpartum depression/anxiety? If yes, how would you rate it on a scale of 1-10?

1

2

3

4

5

6

7

8

9

10

1 is best, 10 is worst
What advice have you received about your current situation? Who provided the advice?
How long does it take the baby to latch on?
How does the baby show they are ready to feed? Who decides when baby will feed?
Have you used any other equipment or supplies (nipple shields, breast shells, etc.)?
Are you experiencing any pain when nursing? If yes, would you rate your pain on a scale of 1-10?
Please use this space to share anything else you want me to know:
Should be Empty: