Lactation Consultation Intake Form
| Mother's Name |
Date of Birth | Address
|
| Home Phone | Work Phone | Cell/Other |
Occupation |
Plan to Return to Work? | Return Date
|
I need help with the following (please be as specific as possible)
|
||
Baby's Name |
Date of Birth | Birth Weight
|
| Lowest weight | Current Weight | #wet and #dirty diapers per 24 hours |
| Jaundice (yes/no) | Highest Bili |
|
| Type of Delivery (vaginal or C-Section) | Medications during delivery (circle those that apply) Epidural Spinal Pain Meds Pitocin Antibiotics Other______________________________________________ |
|
| Hospital Name | OB/Midwife | Phone |
Pediatrician |
Phone | |
| Pregnancy | Normal/Difficult (explain)
|
|
Delivery Complications |
Circle any that apply: Forceps Vacuum Fetal Diseases Baby Early (how much?)___________ NICU Admission |
|
| Maternal History | # other children |
Previous Breastfeeding |
Past Breastfeeding issues (explain) |
||
| Health History (Circle all that apply) |
||
| Smoker |
Thyroid Problems | Diabetes (including gestational) |
| Hormonal disorder/cystic ovaries | Hypertension/swelling post delivery | Depression |
| Breast Surgery | Chronic Conditions |
Allergies (the mothers) |
| Dad's Allergies | Explanation | |
Current Meds or over the counter drugs
|
||
I understand that my doctor is providing all medical care and that a report of this lactation consultation will be sent to my physician(s). I give my permission for information from this consultation to be used to further knowledge of breastfeeding, and give permission for photgraphs to be taken for educational puposes and to promote breast-feeding providing no specific names are used. I understand this consultation will include physical examination of the mother's breasts, the baby's suck and an observation of a breastfeeding session. It may include use of equipment to maintain lactation. I understand that any insurance claims are my responsibility. Signature________________________________________________ Date_______________________
|
||
Print and fax this form to 313.343.5208, or copy and paste
to an email,
and send to scheiwegp@sbcglobal.net.