Name
*
First Name
Last Name
Email
*
Who is your emergency contact?
*
First Name
Last Name
What is your emergency contact's number?
*
(###)
###
####
Date of birth
*
MM
DD
YYYY
What is your baby's name?
*
First Name
Last Name
What is your baby's birth date?
*
MM
DD
YYYY
What is your baby's sex?
*
What was your baby's birth weight?
*
Please list any medications, supplements, or herbs you are currently taking, or have plans to resume while breastfeeding (including contraception and placenta consumption), including dosage.
Please list any drug, food, or environmental allergies.
What is your midwife/OBGYN's name?
*
First Name
Last Name
What is your midwife/OBGYN's fax number?
(###)
###
####
What is your pediatrician's name?
*
First Name
Last Name
What is your pediatrician's fax number?
(###)
###
####
If you wish to have anyone present during our visit, list them here.
*
What is your occupation?
*
Please tell me about the other people who live in your home and their relationship to you.
*
Please indicate if you regularly consume or have plans to resume consumption of any of the following:
*
Please provide any relevant information about the above selections.
What is your current stress level? Low--I feel like I am coping as well as ever. High--I do not feel able to cope at all
*
Please describe your sources of stress.
What is your current pain level? 0- I am not currently in pain. 10 - I am in the most pain I can imagine
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Please describe the sources of the pain you are currently experiencing.
Please tell me if you have any safety concerns for yourself or your baby.
*
Please tell me about your plans to return to work. *
*
Have you discussed pumping at work with your employer? *
*
Tell me about your childcare plans (if applicable):
*
If you are experiencing any of the following post-birth warning signs (check all that apply), call your care provider or emergency services immediately.
*
Have you had any of the following medical conditions?
*
Besides you, does anyone in the baby's family have a history of any of the following?
*
Please provide relevant information about the above selections.
Please check any area where you have a current or chronic health condition
*
Please provide any relevant information about the above selections.
How would you describe your diet?
*
Please tell me about any history of breast surgery or procedures.
Please tell me about any irregularities or concerns with your menstrual cycle.
Please tell me about any history using oral contraceptives, IUD, or other non-barrier birth control.
What changes have you noticed in your breasts?
*
Please select any issues you had during your pregnancy:
*
Where did you deliver your baby?
*
What type of birth?
*
How did your labor begin? Select all that apply.
*
I had the following interventions during my labor (check all that apply):
*
I had the following interventions during my birth (check all that apply):
*
I had the following challenges during the birth (check all that apply):
*
My baby had the following challenges during labor and delivery:
*
My baby had the following interventions while in the hospital:
*
Please provide any relevant information about the above selections.
How long was your total labor and how long was your pushing stage?
*
How many days did you remain in the hospital?
*
How is your recovery going?
When did you first initiate breastfeeding with your baby, and how did it go?
*
Describe the lactation support you received in the hospital.
*
How satisfied were you with the care you received during labor and delivery and postpartum? 1-Empowered and supported 10-Disempowered and unsupported
*
Has your milk come in yet?
*
Please tell me how feeding is going, including information on feedings at the breast and any supplements.
*
Please describe any medical conditions your baby has.
*
If your baby has received a diagnosis of tongue tie, please describe
*
If your baby has had a tongue tie procedure, please list the name of the doctor and the date of the procedure.
Please list any weights recorded for your baby since birth, such as discharge weight or pediatricians, along with dates.
