Lactation Intake Form CARE PROVIDERSPRENATAL & BIRTH HISTORYLABOR & DELIVERYDid you have any of the following interventions during labor?C-SectionFoley balloonCytotecEpisiotomyIV FluidsEpiduralPitocinUse of VacuumUse of ForcepsVaginal FlushAntibioticsInternal Monitoring Membranes strippedWater BrokenDid baby have any of the following challenges? Shoulder dystociaBreech presentationTraverse presentationCord around neckCord prolapseHeart deceleration/fetal distressMeconium aspirationSuctioningDifficulty breathingLow apgar scoreFeverInfectionJaundiceLow blood sugarAntibioticsNG or PEG tubeIVNICU stayMy baby didn’t have any challenges during labor & deliveryBABY’S INFORMATIONBaby’s GenderMaleFemaleOtherFEEDING HISTORYAre you experiencing any of the following? Check all that apply.*Latching difficultiesCracked/bleeding nipplesCreased, flat, blanched nipples after nursingIncomplete breast drainageBaby slides off nipple when trying to latchSore nipplesBaby has a preference for one breastEngorgementBaby not interested in breastBaby falls asleep shortly after starting to feedThrushMastitisBaby always seems hungryBaby excessively gassyLots of spit up (soaking bibs)OtherAre you using any of the following?*NoneNipple ShieldBottleMedela SNSLactAidSyringeCupOtherWhat are you currently feeding baby? *Exclusively BreastmilkExclusively FormulaMainly Breastmilk, Some FormulaMainly Formula, Some BreastmilkEqual Amounts of Breastmilk & FormulaDo you currently notice any of the following during bottle feeding? Check all that apply. *Refusal of BottleCoughing or SputteringGaggingMilk leaking from mouthChewing or ChompingExtended time to finish bottleFinishing bottle in less than 5 minutes.NonePUMPINGSOLIDSBABY’S MEDICAL HISTORYHow did their most recent poop look?*Yellow and SeedyTarry/blackBrownMucusGreenBloodyYOUR MEDICAL HISTORYDo you currently have, or have you had, any of the following? *NoneAnemiaThyroid DisorderDiabetesDepressionAnxietyHigh Blood PressureConstipationYeast InfectionPCOSInfertilityCancerInsulin ResistanceMuscle Aches & PainsRetained PlacentaRefluxTongue TieVisual ImpairmentInsomniaSleep DisorderAutoimmune DisorderFatigueOtherAny prior breast surgeries or piercings?*NoneBiopsyImplants (behind muscle)Implants (in front of muscle)ReductionPiercingsIs there a family history of any of the following: *NoneFood allergiesRefluxReductionOtherLIFESTYLE HISTORYPlease tell me about your diet: *Gluten-freeDairy-freeVegasVery HealthyFairly HealthyPoorCONSENTI verify that the above information is correct and true. *Consent for treatmentI verify that I have read the Consent for Treatment in it’s entirety and agree to all.*EmailSubmit Please enable JavaScript in your browser to submit the form Serving the Portland Metro area in-person, or via teletherapy anywhere in Oregon.
