1 Contact and general information 2 Lactation Intake Form 3 Breastfeeding Parent Health History 4 Baby’s Health History 5 Consent to Treat
Baby’s Name:
Date of Birth:
Gestational Age?:
Current Age?:
Birth Weight:
lbs/oz
Kg
Discharge Weight:
Does the baby have any medical issues of which we need to be aware? YesNo
(Please Explain)
Hospital
Birth Center
Home
Other
Vaginal birth
C-Section
VBAC
Vacuum
Forceps
Spontaneously
Induction
Length of labor
Hemorrhage? Meds?
Medications during labor and delivery (pain, meds, antibiotics, etc)
Any complications/ procedures such as jaundice, hypoglycemia, circumcision, NICU stay, etc? Did this cause separation between you and your baby?
Baby’s Doctor Name:
Doctor’s Phone Number:
Infant Feeding Method(s)
Breast
Bottle
SNS
Syringe
Cup
Baby is fed:
breastmilk only
formula only
both (Amount of supplemental formula)
Does baby take both breasts at each feeding?
Yes
No
Sometimes
Baby not latching
Number of feedings in 24 hours?
How long does the baby stay on the breast at each feeding aprox?
Does the baby use a pacifier?
Some
# diapers in the last 24 hrs? Wet
Dirty
Do you have a breast pump?YesNo
If yes, what kind of pump?
How often do you pump?
When did you begin pumping?
How much do you collect at each session?