Lactation Client Intake Form

Step 1 of 2

What is babies birthdate?*

What was babies guess date (estimated due date)?*

Where did you give birth?*

Home
Hospital
Birth Center

How was your baby born?*

Vaginally
Cesarean

What is your primary providers name?*

What is your primary providers email or fax #?*

May I send notes of our visit to your primary care provider?*

yes
no

Mother's First Name*

Mother's Last Name*

Mothers Birthdate*

Address*

Address Line 2

City*

State*

Zip Code*

Mothers Phone*

E-mail*

Mothers Occupation

Partners name?

E-mail

Phone

Will your partner take time off work after the baby is born? If so, how long?

Babies name?

What was babies birth weight?

What were babies APGAR scores, if known?

Lactation Questionnaire (Step 2)

Please list any complication with birth or your infant, if any?

Your other children (names and ages):

How many previous births have you had?

Miscarriages?

Did you breastfeed? How long?

Did you experience any problems with nursing your other children?

Who are your support people (partner, friends, family etc.)? Explain.

Have you had any breast surgeries in the past?

Have you experienced any of the following?*

Please explain.

How long do you you plan on breastfeeding?*

1 month
2 months
3 months
6 weeks
6 months
9 months
1 year
Until we decide to stop.
Other

If other please explain?

Did you have any complications in previous pregnancies? If yes, please explain.

Did any of your babies need special care after birth?

Did you experience postpartum depression? Please explain

What supports do have in place to help during this postpartum time?

Did your breast grow larger in pregnancy?

How long after birth did you nurse your baby?

Approximately how long after birth did your milk come in?

Did or were your breast engorged.

How many times has your baby nursed in the last 24 hours?

About how long does your baby nurse on your left side per feed?

About how long does your baby nurse on your right side per feed?

Does your baby nurse on one side per feed or both?

Approximately how many wet diapers has baby had in the last 24 hours?

What does babies poo/stool look like?*

Black and tar-like
Brown/black “soupy”
Green
Yellow

Does your baby have difficulty latching?

Is it painful to nurse?

Are you pumping? If so how many times a day?

Are your breasts painful? If so, please explain.

Are your nipples sore? If so please explain.

What brings you to Steph, CLC, for lactation support?

By submitting this form you give consent to Stephanie Holthus, CLC, to assist in your breastfeeding goals. Payment is due at the time of service.

Lactation Intake Form