Infant Assessment Form
Infant's name
First Name
Last Name
Infant's Date of Birth
/
Month
/
Day
Year
Date
Guardian's phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian's Email Address
example@example.com
Guardian's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Problems?
Heart Disease
Bleeding Disorder
Other
Infant's Gender
Male
Female
Birth Hospital
Birth Weight
Present Weight
Vaginal or C-Section Birth
Vaginal
C-Section
Any birth complications?
Are you presently breastfeeding?
Yes
No
If no, how long since you stopped breastfeeding
Medical History
How long does baby take to eat?
Infants are usually given vitamin K at birth. Did your child receive the vitamin K shot?
Yes
No
Was your infant premature?
Yes
No
If Yes, how many weeks?
Does your infant have any heart disease?
Yes
No
Has your infant had any surgery?
Yes
No
Has your infant experienced any of the following?
Please check any that apply
Shallow latch at breast or bottle
Falls asleep while eating
Slides or pops on and off the nipple
Colic symptoms/ Cries a lot
Reflux smyptoms
Clicking or smacking noises when eating
Spits up often?
Gagging, choking, coughing when eating
Gassy (toots a lot) / Fussy often
Poor weight gain
Hiccups Often
Lip curls under when nursing or taking bottle
Please check any that apply
Gumming or chewing your nipple when nursing
Pacifier falls out easily, doesn't like, won't stay in
Milk dribbles out of mouth when nursing/bottle
Short sleeping requiring feeding every 1-2 hrs
Snoring, noisy breathing or mouth breathing
Feels like a full time job just to feed baby
Nose congested often
Baby is frustrated at the breast or bottle
Other
How long does baby take to eat?
How often does baby eat?
Is your infant taking any medications?
Yes
No
Name of medication
Has your infant had a prior surgery to correct the tongue or lip tie If yes, when, where, and by whom?
Do YOU have any of the following signs or symptoms?
Please check any that apply
Creased, flattened or blanched nipples
Lipstick shaped nipples
Blistered or cut nipples
Bleeding nipples
Poor or incomplete breast drainage
Infected nipples or breasts
Plugged ducts/engorgment/mastitis
Nipple thrush
Using a nipple shield
Baby prefers one side over the other
Other
Pain on a scale of 1-10 when first latching
Pain on a scale of 1-10 during nursing
Pediatrician
Pediatrician Phone number
Format: (000) 000-0000.
Lactation Consultant
LC's Phone number
Format: (000) 000-0000.
Who referred you to us?
Submit
Should be Empty: