Lactation Pre-Consult Intake Form
Kristen Bindel, CLC
Email
example@example.com
Breastfeeding/Chestfeeding Parent Name
First Name
Last Name
Parent D.O.B
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Infant's Name
First Name
Last Name
Infant D.O.B
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Partner or Co-Parent Name if applicable
First Name
Last Name
Reason for Consult
Pain
Latch
Concerns for Infant Growth
Breast Refusal
Bottle Refusal
Other
If reason for consult is "other" please explain below.
What is your feeding goal?
Infant's most recent weight?
Date of most recent weigh-in?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
In the past 24 hours, how many feedings has baby had? (Ok to give an approximation)
Baby's feedings have been by:
Breast
Bottle
Other feeding device
Formula
Breastmilk and Formula
How many wet diapers has your baby had in the past 24 hours? (Approx is ok)
How many bowel movements has your baby had in the past 24 hours? (Approx is ok)
Does your baby wake to eat?
Yes
Sometimes
No, I wake up baby to eat
From the start of one feed to the start of the next feed, how much time passes in between?
What positions have you tried and are most comfortable with?
Football
Sidelying
Reclined
Cradle
Cross Cradle
Other
Is feeding comfortable?
Yes
No
Sometimes
Yes, after a few tries
Painful
Unable to latch
Other
If "Other" was chosen, please explain
How does baby act after feeding?
Relaxed & happy
Upset & fussy
Other
If "Other" was chosen, please explain
Does baby use a pacifier
Yes
No
Do you use a nipple shield to aid in nursing?
Yes
No
Do you use any medications? Please list.
Has baby had any illnesses?
Have you had any breast surgeries? If so, please explain.
Baby was born at how many weeks gestation?
Were there any complications during labor and delivery
Do you use a breast pump or milk collecting device?
Yes - Pump
No
Hakaa
Hand expression
Sleeping Arrangement
Nursing parent and baby share a room but not a bed.
Bed-Sharing/Co-sleeping
Baby in crib/bassinet in seperate room
Submit
Should be Empty: