1 Contact and general information 2 Lactation Intake Form 3 Breastfeeding Parent Health History 4 Baby’s Health History 5 Consent to Treat
Today’s date:
Referred by:
E-mail address:
Did you see a lactation consultant before? YesNo
Lactation Consultant Name?:
Milk Supply Concerns (Over/Under Supply)Sore or painful nipples and/or breastsProblems with latching baby onto the breastPumping and storing breast milkEngorgement or mastitis symptoms
Other: