Lactation Intake Form

Date

Mother’s Name

Age

Occupation

Father/Mother (Partner’s) Name

Age

Father/Mother (Partner’s) Occupation

Address

Phone

Infant’s Name

Sex

Current Age

Date of Birth

Due Date

Weeks Early/Late

Delivered at which hospital

Birth Weight

Baby Delivered by

C-Section Vaginal APGARS (if known)

List any complications at birth for you or your infant

Number of Pregnancies

Number of live births

Ages of other children

If you nursed your previous children, how long did your nurse?

Did you have any problems?

Medical Problems or Conditions. Please list any major surgery or conditions.

Mother

Infant

Please list any medications or herbs you are currently taking

Please check whether you have experienced any of the following:

Depression

Yes No

Infertility

Yes No

Breast Surgeries

Yes No

Gestational

Yes No

High Blood Pressure

Yes No

Polycystic Ovary Syndrome

Yes No

Diabetes

Yes No

Allergies

Yes No

Thyroid Problems

Yes No

Are you a vegetarian? If yes, which type? Vegan or?

History of any heart conditions or heart arrhythmias?

Lactation Questionnaire

1. Did your breasts grow larger during your pregnancy? How much?

No Change ½ cup size up One cup size or larger

2. How soon after delivery did you nurse your baby?

Less than one hr. 1-3 hrs. 4-10 hrs. over 10 hrs. never nursed

3. Approximately, how soon after delivery did your milk come in?

48 hours 72 hours 4th day 5th day Not sure

4. Are/were your breasts engorged?

Not Sure Slight Moderate Severe

5. Are your legs or ankles swollen

No Yes

If yes:

Slight Moderate Severe

6. How many times has your baby nursed in the last 24 hours?

No Breastfeeding Less than 4 times 4 – 6 times 7 – 9 times 10 times

7. One the average, how many minutes does your baby nurse per side?

Left Brest:

0 – 5 min. 5 – 10 min. 15 – 20 min. more than 20 min.

Right Breast:

0 – 5 min. 5 – 10 min. 15 – 20 min. more than 20 min.

8. Does your baby nurse one breast per feeding?

Yes No

9. How many wet and soiled diapers has your baby had in the last 24 hours?

Wet Diapers:

Less than 3 4 – 5 6 or more

Stools/Poops:

Less than 3 4 – 5 6 or more

10. Stools/poops color and consistency:

Black and Tar-like Brown/black “soupy” Green Yellow

11. Does your baby have difficulty latching?

Yes No Sometimes

12. Is it painful to nurse?

Yes No At the start of a feeding For the entire feeding

13. Are you pumping? If so, how many times daily?

No Pumping 1 – 2 times daily 3 – 4 times daily 5 – 7 times daily 8 or more times daily

14. How much do you pump per session?

Which name brand pump are you using?

15. Is your baby supplemented with formula or expressed breast milk? How often and much?

Formula:

Expressed Breast milk:

16. Are your nipples sore?

Yes No

Explain

17. Are your breasts painful?

Yes No

Explain

I authorize the lactation consultant to perform a physical assessment of my infant and examine my breasts

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Mother’s Signature

Date

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