Oak Park Pediatrics Lactation Consult Intake Form

Name of mom:

Name of baby:

Your OBGyn/Midwife:

Phone number

Why are you here today? What can the doctor help with?

What are your breastfeeding goals? Short term, long term? How long do you hope to breastfeed?

What are your previous breastfeeding experiences?

What is your occupation?

Length of maternity leave?

About this pregnancy and baby:

What number pregnancy is this for you?

What number baby is this for you?

How many weeks gestation was the birth?

Vaginal or C-section?

Any complications during the pregnancy?

Did you experience breast changes during pregnancy (increased size, firmness, discharge)?

Yes No

If yes, what changes?

About this delivery:

Any complications during the delivery or afterwards (for you or baby)?

Feeding Details:

How many times do you breastfeed at the breast each day?

Minutes

On which sides? (select one):

Left Right Both Alternating

Are you pumping? (select one)

Yes No

If yes, how many times/day:

minutes (circle one)

In addition or Instead of breatfeeding

Approximately how much do you pump at each pump session?

Left breast:

Select One

oz ml

Right breast:

Select One

oz ml

What kind of pump do you have?

How much milk does your baby get by bottle/soft feeder/other feeding device per feeding?

Select One

oz ml

How many times/day?

Does your baby take a pacifier (circle one)?

Yes No

Elimination

About how many wet diapers does your baby have each day?

About how many poops does your baby have each day?

What is the color/consistency of your baby’s poop?

Medications taken during pregnancy (please list):

Current Medications (please list below):

Add new row

Please give details of any positive responses above:

If you are having breast pain, please circle any of the following that apply: (Please specify which breast, if only one)

Nipple pain only

Deep breast pain

Pain worse between feedings

Burning or shooting pain

Pain worse with latch

Deep aching pain

Pain better while nursing (after initial latch)

Does YOUR BABY have any of the following? (check all that apply)

Difficulty latching

Excessive spit-up

Falling asleep easily during feedings

Short of breath while feeding

Noisy eating

Not waking up on his/her own for feedings

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