Lactation Intake Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Baby's Birth Weight
Baby's Last Weight and Date
Mother's Date of Birth
-
Month
-
Day
Year
Date
Baby's Date of Birth
-
Month
-
Day
Year
Date
Baby's Gender
Please Select
Male
Female
Type of Delivery
Please Select
Vaginal
Cesarean
Were there any complications during pregnancy or birth? Explain.
L&D Interventions
None
Failed Induction
Epidural
Episiotomy
Magnesium Sulfate
Pitocin
Vacuum
Please Select Feeding Methods
Exclusive breastfeeding
Breast and bottle feeding, only breastmilk
Breast and bottle feeding, formula
Exclusively pumping and bottle feeding
If providing bottles, how many bottles are given per day?
If providing formula, how much is given and how often?
Breastfeeding Goals
Breastfeeding Tools
Rows
Present use
Past use
Never
Nipple Shield
Nipple Shell
Silverette Cups
Supplemental Nursing System
Nipple Cream
Lactation Supplements
If you are pumping, how often and for how long?
What kind of breast pump(s) do you use?
What size flanges are you using?
If using a nipple shield, what size do you use?
Maternal Nutrition
Hydration is important during breastfeeding, are you drinking at least 128 oz of water per day?
Yes
Improving
Needs improvement
No
Breastfeeding requires additional caloric intake. Are you eating 2-3 well rounded meals and having snacks between?
Yes
Improving
Needs improvement
No
Gynecological History
Health History
Post partum depression
Toxemia
Gestational diabetes
Baby over 8 pounds
Chronic hypertension
Gestational hypertension
PCOS
Anxiety
Anemia
Excessive blood loss during or after birth
Reynaud's Syndrome
Thyroidism
How many living children do you have?
Gynecological History cont.
Rows
Present use
Past use
Never
Birth control pills
Hormonal patches
Nuva Ring
Condom
Diaphragm
Hormonal IUD
Non-hormonal IUD
Partner Vasectomy
Gynecological History cont.
Fibrocystic breasts
Endrometriosis
Fibroids
Infertility
Painful periods
Heavy periods
PMDD
Irregular periods
Medication history
Rows
Currently
Past use
Rarely used
Never
NSAIDs (Advil, Motrin, Ibuprofen, Aspirin, etc.)
Tylenol (Acetaminophen)
Acid blockers (Tagamet, Zantac, Prilosec, etc.)
Antibiotics
Steriods
Oral contraceptives
Please list the prescription medications and supplements you are taking.
Additional comments
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