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Client InformationMotherFirst Name *
Last Name *
Date of Birth *
Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountry
Physician or Midwife
Physician's/Midwife's Phone Number
Date of Birth
Place of Birth
Birthweight (Pounds and Ounces)
Physician/Healthcare Provider's Phone Number
Continue to next section: Breastfeeding and Health History Questionnaire 1 / 2 Breastfeeding QuestionnaireDescribe any feeding problems that concern you
Family HistoryDoes anyone on either side of the baby's family have any of the following? Allergies to foodsEnvironmental allergiesAsthmaEczemaHay feverBreast cancerDiabetesGenetic diseaseThyroid diseaseOther
What age were you when you had your first menstrual period?
Were your periods: RegularIrregular
Was this your first pregnancy? YesNo
If no, how many pregnancies?
How many children?
Did you breastfeed your other children? YesNo
Which of the following family planning methods are you using or do you plan to use? (Mark all the apply.) NorplantBirth control shotBarriersBirth control pillsVasectomyNatural family planning/rhythmTubes tiedNone
Will you be returning to work/school? YesNo
Full or part time? FullPart
Pregnancy and Birth HistoryDoes your baby have any known health problems? Please describe.
Is the baby currently on any medications? Please describe.
Are you taking any of the following? Prenatal vitamin-mineralIronAntihistaminesCold remediesAntibioticsAspirinLaxativesDiuretics/water pillsAntacidsBirth control pillsPain pillsDiet pillsHerbs
Have you ever had any of the following related to your breasts? BiopsyLumpsImplantsBreast reductionNipple problems
Do you presently have or have you ever had any of the following? AnemiaAllergy/asthmaDiarrhea (chronic)Heart diseaseDiabetesHepatitiesVenereal diseaseHigh blood pressureLiver diseaseThyroid disordersMiscarriagesHemorrhoids cancerInfertilityAbortionsDepressionSexual abuseAbnormal pap smearConstipationEating disorderKidney/bladder disease or infectionYeast infectionsTuberculosisPolycycstic ovarian syndrom
Did you have any of the following during this pregnancy? Premature laborGestational diabetesHigh blood pressureNausea/vomiting - severeAnemiaFeverUrinary tract infectionsMedications
Did you have any of the following during this labor and delivery? Premature rupture of membranesDrugs to control painDrugs to control high blood pressureEpiduralFeverAntibioticsDrugs to induce or speed labor?Hemorrhage
What type of delivery did you have with this birth? VaginalEmergency c-sectionPlanned c-section
Gestational age of baby at birth (in weeks)
Did you have any of the following with this birth? Total labor longer than 30 hoursEpisiotomy or tearPushing stage longer than 2 hoursBreech presentationTear that involved the rectum (3rd or 4th degree tear)Forceps deliveryVacuum extractions
Did you experience any postpartum complications? Urinary/other infectionsLow blood pressureHigh blood pressureExcessive bleeding or hemorrhaging
Did the baby have any of the following after birth: Breathing difficultiesHigh hematocritLow blood sugarMeconium aspirationJaundice
Highest bilirubin level (if known/tested)
Breast changes since birth Hard/engorgedHeavyWarmLeakingNo changes
Bra size before pregnancy
Bra size now
Breastfeeding HistoryHow old was your baby when you first realized that you were having breastfeeding difficulties?
Describe any breastfeeding supplies or breast pumps you are using
Has your baby been supplemented with any of the following? WaterSugar waterFormulaExpressed breastmilkDonor breastmilk
Type of formula, if used
If supplemented, how was the baby supplement given? Feeding tubeFinger feedingCup feedingBottle
Type of bottle
Number of supplements in past 24 hours
Quantity of supplement given per feeding
How many times have you breastfed your baby in the past 24 hours? 7 or less8-12 times13 or more
Are you experiencing any of the following? Latch-on difficultiesEngorgementSleepy babySore nipplesPreference for one breastBaby not interestedCracked/bleeding nipplesBreast painFeeling that there is not enough milkBaby crying excessivelyBaby always seems hungry
Is the baby content or sleeping between feedings? NeverOcassionallyOftenAlways
What is the longest your baby has gone between feedings during the day?
What is the longest your baby has gone between feedings during the night
Who decides a feeding is over? MomBaby
How many breasts per feeding? One breastBoth breasts
How long does baby nurse?
For how long do you wish to breastfeed your baby or what is your breastfeeding goal? 1 month2-3 months4-6 months6-9 months12 monthsLonger than 12 months
Does your baby use a pacifier? YesNo
If so, how often?
Number of wet diapers in the last 24 hours.
Number of stools in the last 24 hours?
Were the stools bigger than a tablespoon? YesNo
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