Lactation Intake Form

Please correct the errors described below.

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

Please list any medications or herbs you are currently taking

Please check whether you have experienced any of the following:

Lactation Questionnaire

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

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

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

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

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