Breastfeeding Parent's Information * First Name Last Name * Date of Birth MM DD YYYY * Email Phone Number (###) ### #### * Date of Birth MM DD YYYY Emergency Contact First Name Last Name Phone Number (###) ### #### Relationship Baby's Information * First Name Last Name * Date of Birth MM DD YYYY * Gestational Age at Birth * Birth Weight * Current Weight * Birth Place Homebirth Birth Center Hospital Other Who was your care provider for the majority of your prenatal care? Pediatrician’s Name Pediatrician’s Phone (###) ### #### Birth Details * Mode of Birth Vaginal birth Assisted vaginal delivery (ex. vacuum, forceps) Cesarean birth * Was labor Spontaneous Induced or augmented with medication * Did you receive pain medication or an epidural during labor? Yes No Were there any complications during or after birth (for you or your baby)? Yes No Was your baby placed skin-to-skin soon after birth? Yes No * Was your baby separated from you after birth (NICU stay or other reason)? Yes No Was any formula, donor milk, or expressed milk given at the hospital? (if applicable) Yes No * When did your baby first feed after birth? Within the first hour 1-3 hours after birth More than 3 hours after birth I am not sure Feeding History * What are your current feeding goals? Exclusive breastfeeding Combination feeding (breast + bottle) Pumping exclusively Formula feeding Unsure/still exploring * Is this your first baby? Yes No * How often does your baby feed in 24 hours? <8 times 8–12 times >12 times Unsure * How does your baby usually feed? Direct breast Bottle (expressed milk) Bottle (formula) Supplemental Nursing System (SNS) Syringe/cup/other * Do you experience any of the following? Painful latch Cracked or bleeding nipples Engorgement or fullness Blocked ducts/mastitis Low milk supply concerns Oversupply Baby falls asleep quickly at the breast Clicking or leaking while feeding Baby refuses breast * Please describe your main concern(s): * Has your baby been evaluated for: Tongue tie Lip tie Reflux Jaundice Weight concerns Eczema Oral thrush Milk allergy Cleft Other Does baby have any medical concerns? Pumping Information (if applicable) * Do you pump? Yes No Pump type Manual Electric Wearable Hospital-grade Brand & model: How often do you pump? Average amount per session Do you experience discomfort while pumping? Yes No Falange size Has your baby had any supplements or formula? Yes No Mother's Health Any medical conditions that could affect milk production (e.g., thyroid, PCOS, diabetes)? * Are you taking any medications or supplements? Yes No * Have you had previous breast surgery (augmentation, reduction, biopsy)? Yes No Feeding Environment & Support * How do you feel your feeding experience is going overall? * Please describe your support system for feeding (partner, family, friends)? Anything else you’d like me to know before we meet? Appointment Preferences * Preferred appointment location Virtual In-home visit Office visit (at my home-office in South Philly) * Best days/times for appointment Thank you for completing this intake form!Your information helps me prepare to best support you and your baby with personalized, evidence-based care. 💛 Lactation Counseling Intake Form
