Lactation Intake Form Please enable JavaScript in your browser to complete this form.1. First and Last Name *2. Email Address *3. Phone number *4. What is your preferred method of communication? Check all that apply. *PhoneTextEmail5. Address (include city and zip code) *6. Why are you requesting a Lactation Consultation today? Please be as specific as possible.7. Birth Parent's Dr and Clinic (midwife, birth doula, etc)8. Pediatrician Name and Clinic9. Baby(ies) Name(s)10. Baby(ies) Birthdate *11. Baby(ies) Due Date *12. Delivery Location13. Baby(ies) Birth Weight (specify for each baby if multiples)14. Baby(ies) Weight at Discharge (specify for each baby if multiples) 15. Baby(ies) Current Weight (specify for each baby if multiples)16. Delivery Notes (please check all that apply) *Vaginal DeliveryC-sectionJaundice (if yes, please describe treatment in "other" box)Other (please specify)17. Hospital History (was your baby in Special Care or NICU? Describe)18. Medical History (please check all that apply) *Polycystic ovarian syndromeInfertilityDiabetes (including gestational)AnemiaHormonal disorderHigh blood pressureLow blood pressurePre-eclampsiaSevere swelling during pregnancy/after birthDepressionAnxietyEating disordersHerpes virusHIV/AIDSNone Other (please specify)19. Breast History (please check all that apply) *Augmentation (if yes, please enter date of procedure in comment box)Reduction (if yes, please enter date of procedure in comment box)Accident/Injuries/Burns (if yes, please enter details in comment box)PiercingsNone Other (please specify) or None20. Feeding Plan- please be as complete as possible21. Current Daytime Feeding Habits22. Current Nighttime Feeding Habits23. Date milk came in (please answer, even if not currently breastfeeding)24. If breastfeeding or pumping, what is your current breastmilk output?25. Current medications (include prescribed and over-the-counter medications for mom and baby, please)26. Was your conception medically assisted? If yes, please explain.27. Delivery Complications (please check all that apply)Failure to progressFetal distressMaternal distressHemorrhage following birthNICU admissionNone Other (please specify)28. After birth, were you and your baby separated? If yes, please explain.29. Have you ever taken a Breastfeeding class? Where?30. Did you have a lactation counselor in the hospital or doctor's office? If yes, please describe how that went for you.31. Are you using a pump?YesNo32. Are you using pacifiers?YesNo33. Is there a family history of orthodontal interventions and/or speech or feeding issues? This would include "tongue tie" or "lip tie". If yes, please explain.34. Describe any additional important information about your baby(ies).35. How did you hear about Welcome Baby Care?Heard an ad on the radioSaw a post on Social MediaReferral from current or former client (enter name below)Referral from a birth or postpartum professional (enter name below)Online search (enter search term below)Please enter name of referrer or online search term below:36. Thank you for completing the Lactation Consultation intake form. If you have any other comments or questions, please enter them in the comment box. A Welcome Baby Care Lactation Counselor will contact you within one business day to review your answers, get any additional necessary information and schedule your consultation. Submit
