Name *

First Name

Last Name

Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date *

Estimated Due Date

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your Date of Birth

MM

DD

YYYY

Baby's Estimated Due Date

MM

DD

YYYY

Baby's Date of Birth

MM

DD

YYYY

Do you smoke?

No

Yes

Was this your first pregnancy?

Yes

No

Are you currently on birth control?

Yes

No

What type of birth did you have with this pregnancy?

check all that apply

Vaginal (went into labor on your own)

Vaginal (induction)

Vacuum/forceps

Unplanned C-Section

Planned C-Section

Did you have any of the following with this birth

Check all that apply

Premature rupture of membranes

Antibiotics

Epidural

Other pain medications

Pitocin

Total labor longer than 30 hours

Pushing stage longer than 2 hours

Episiotomy

Tear

Hemorrhage

Did you have any postpartum complications?

Check all that apply

Urinary/other infection

Low blood pressure

High blood pressure

Retained placenta

Excessive bleeding

Did baby have any of the following?

Check all that apply

Breech presentation

Umbilical cord problems

Meconium aspiration

Breathing difficulties

Low blood sugar

Jaundice

What is your baby's most common state?

Sleeping/sleepy

Quiet alert/calm

Fussy

Crying

Does baby wake on his/her own for feeds?

All feedings

Most feedings

Some feedings

Must wake for all feedings

Pacifier use

None

Rarely

Sometimes

Often

Where does baby sleep at night?

In his/her own room

crib/bassinet in my room

In my bed

On my chest

Did you take a prenatal breastfeeding class?

Yes

No

Did your breasts become larger during pregnancy?

Yes

No

Breast changes since birth

Check all that apply

No changes

Hard/engorged

Heavy

Warm

Leaking

Was baby's first feeding at the breast?

Yes

No

Does your baby drink from bottles

No

Yes, breast milk

Yes, formula

Does one breast produce significantly more milk that the other?

No

Yes, left

Yes, right

Signature

First Name

Last Name

Date

MM

DD

YYYY

● I give my consent for the lactation counselor (Mandy Spann, CLC) to work with me and my baby during this consultation for my breastfeeding problem/concern. This consent is for in person visits, as well as phone conversations, and any information sent/communicated by email, mobile phone, fax, SMS text messages, and/or private social media. I understand that electronic/cellular forms of communication may not be encrypted/secure ● I understand that a lactation consultation may involve: ○ touching my breasts and/or nipples for the purposes of assessment ○ inserting gloved fingers into my baby’s mouth to assess suck ○ observation of a breastfeed, and suggestions to enhance latch or position ○ demonstration and use of equipment or supplies that may be recommended ○ demonstration of techniques designed to improve breastfeeding ● I understand a partial or follow up visit is sometimes necessary. I understand that breastfeeding supplies and/or breast pumps may be recommended as effective management of specific situations. ● I understand that I am responsible for informing the lactation counselor of changes I feel are necessary in the care path at the time of the visit or during the course of follow up communications. I understand it is my responsibility to call the lactation counselor with progress reports, questions or concerns. ● I give my consent for the lactation counselor to use clinical information and any photographs obtained during our sessions for conferring other health care providers and education of mothers about lactation. I won’t be identified in any way, but aspects of my situation may be described and discussed. ● I understand total payment is expected at the conclusion of the consultation. I also understand that no refunds will be given for services rendered. ● I understand that for this lactation consultation and all follow ups, the lactation counselor will protect the privacy of my personal health information as required by the Code of Ethics of the Academy of Lactation Policy and Practice. *

I Consent

Name

First Name

Last Name

Date

MM

DD

YYYY