1 Contact and general information 2 Lactation Intake Form 3 Breastfeeding Parent Health History 4 Baby’s Health History 5 Consent to Treat
Current Medications, Supplements, or Herbs:
OB/GYN or Midwife:
Do you have any medical issues of which we need to be aware? YesNo
(Please Explain)
Infertility treatment
Anemia (low iron)
PCOS
Depression
Food Allergies
Diabetes Type 1Type 2Gestational
Controlled by DietMedicationInsulin
Hypertension ChronicPregnancy Induced
Thyroid issues:
Weight loss Surgery:
Breast Surgery/ piercing:
Neck or Back Injury/Pain:
Pregnancies:
Living children:
Have you ever breastfed before? YesNo
How was that experience, any challenges?
Natural Wean
Forced Wean
Milk Supply Concerns (Over/Under Supply)
Sore or painful nipples/breasts
Latching baby onto the breast
Engorgement
Other: