Medical Intake form

Lactation Intake Form
Name

First NameLast Name
Email
example@example.com
Phone Number
Baby's Birth Weight
Baby's Last Weight and Date
Mother's Date of Birth

MonthDayYear
Date
Baby's Date of Birth

MonthDayYear
Date
Baby's Gender
Type of Delivery
Were there any complications during pregnancy or birth? Explain.
L&D Interventions

NoneFailed InductionEpiduralEpisiotomyMagnesium SulfatePitocinVacuum
Please Select Feeding Methods

Exclusive breastfeedingBreast and bottle feeding, only breastmilkBreast and bottle feeding, formulaExclusively 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?

YesImprovingNeeds improvementNo
Breastfeeding requires additional caloric intake. Are you eating 2-3 well rounded meals and having snacks between?

YesImprovingNeeds improvementNo
Gynecological History
Health History

Post partum depressionToxemiaGestational diabetesBaby over 8 poundsChronic hypertensionGestational hypertensionPCOSAnxietyAnemiaExcessive blood loss during or after birthReynaud's SyndromeThyroidism
How many living children do you have?

Gynecological History cont.

Gynecological History cont.

Fibrocystic breastsEndrometriosisFibroidsInfertilityPainful periodsHeavy periodsPMDDIrregular 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

Lactation Intake Form