Contact Information

    Mother's Name:

    Baby's Name:

    Baby's DOB:

    Baby's Sex:

    Baby's Due Date:

    Gestational age at birth:

    Do you give consent for the lactation consultant to work with you during this consultation?

    Do you consent to you, or your baby being recorded or have photos taken?

    You and Your Baby's Medical History

    Please list any medication, supplements, or herbs you or babcy are currently taking.

    Please describe any food or environmental allergies (including sensitivities and intolerances if applicable) for yourself or baby.

    Please indicate here if you have a current or chronic condition in any of the following categories.

    Other

    Pregnancy (skip if not applicable)

    How many weeks are you:

    When is your due date:

    Have you noticed any size changes in your breasts?

    Do you have any complications or conditions?

    Labor and Birth

    What type of birth did you have:

    How long was labor:

    Where did you give birth to your baby:

    How long was the pushing:

    What interventions did you have:

    Baby Medical History

    Did the baby have any conditions at birth?

    Did the baby have any interventions/medical procedures at the hospital?

    Please provide the names of any healthcare providers other than your pediatrician involved in your baby's care.

    Anything else you'd like us to know

    Feeding History

    Please tell us about any issues or concerns you're currently having related to breastfeeding (supply, pumping, latching, routines, returning to work, etc.)

    Please tell us about any issues or concerns you're currently having related to your baby

    Diapering Information

    Wet diapers per day:

    Stools per day:

    Color of stools:

    Consistency of stool:

    Feeding Information

    Does your baby do any cluster feeding (if so, when)?

    How often does your baby sit up?

    If your baby has any digestive issues, please describe.

    Breastfeeding

    How many times does your baby feed in 24 hours:

    Length of a typical feeding:

    Rate your breast pain (1-10):

    Any other breast-feeding issues?

    Supplementation

    If not using a bottle or supplements please leave blank.
    What are you giving to your baby?

    How many times in 24 hours:

    Average amount each type:

    What brand and type of formula are you using:

    Pumping

    Do you have any concerns about pumping?

    Flange size:

    How many times a day do you pump:

    What is the average amount you are expressing each time:

    What pump(s) are you using:

    What is the total amount you are pumping each day:

    How long is each session (minutes):

    PLease list any weights recorded for your baby since birth, such a discharge weight and any pediatrician visits, along with dates.

    Document(s):

    Initial Lactation Form