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MotherBorn Lactation Services

Dana L. Ehman BA, IBCLC, RLC

www.motherborn.com

dana@motherborn.com

610-299-1038

Today's Date *

Appointment Date *

Appointment Time *

Patient Information- MOTHER

Mother's First Name *

Middle Initial

Mother's Last Name *

Mother's Date of Birth *

Mother's Email Address *

Preferred Phone Number *

Phone Type *

Alternate Phone

Phone Type

Street Address *

City *

Zip Code *

Insurance Carrier *

Insurance ID (Aetna, Blue Cross Plans, Keystone) Card must be presented at consultation

Relationship to Insured (Aetna, Blue Cross Plans, Keytstone)

Insured's Full Name if different from Mother (Aetna, Blue Cross Plans, Keystone)

OB/Midwife Practice Name *

OB/Midwife at Delivery Name *

OB/Midwife Address- City Only *

Hospital/Birth Facility *

Patient Information- Infant A

Infant's First Name *

Middle Initial

Infant's Last Name *

Infant's Date of Birth *

Infant's Birth Weight *

Infant's Discharge Weight

Pediatric Practice Name *

Pediatric Address- City Only *

Last Pediatrician Seen *

Patient Information- Infant B

Infant's First Name *

Middle Initial

Infant's Last Name *

Infant's Date of Birth *

Infant's Birth Weight *

Infant's Discharge Weight

Pediatric Practice Name *

Pediatric Address- City Only *

Last Pediatrician Seen *

How did you find us OR who referred you to MotherBorn?

In your own words, what is your primary complaint or concern for this visit?

What are you goals for the lactation visit(s)?

Patient History Form

Mother- Past Medical History: Do you have now or ever had? If NONE check NONE *

Other Comments on Past Medical History

Mother- A Review of Systems: Do you have now? Check all that apply- if nothing applies, check NONE

Constitutional *

Skin *

Musculoskeletal *

Psychiatric *

Endocrine *

Allergy/Immunology *

Breast Conditions *

Are you allergic to any medications? *

Yes

No

I am allergic to the following medications:

Past surgeries?

An dietary concerns?

List any natural or alternative therapies: chiropractic, magnets, massage, herbals:

List any additional conditions or concerns here:

Social History

Marital Status *

Spouse

Partner

Single

Do you have help at home? *

Yes

No

Smoking History *

None smoker

Current smoker

Ex smoker

Alcohol consumption *

Never

Occasional

Frequent

Attended Breastfeeding Class *

Yes

No

Attended Childbirth Class *

Yes

No

Previous Pregnancies? *

Yes

No

Previous Births? *

Yes

No

Previous breastfeeding length?

About your current birth

Were the babies premature? *

Yes

No

Gestational Age of Babies? *

Type of birth and interventions or complications *

Any stressful complications?

Complications after delivery? *

Enter any additional comments here:

Tell me about your breastfeeding experience so far. Check off all that apply for both babies. We will discuss in detail during the visit.

Are you experiencing- Check all that apply *

Please list other issues or concerns here:

High Blood Pressure	Heart Disease	Heart Surgery
High Cholesterol	Headaches	Kidney Stones
Kidney Disease	Cancer	Asthma/COPD
Stroke/CVATIA	Seizures	Stomach Ulcer
Liver Disease	Blood Clots	Diabetes- Gestational
Diabetes- Insulin Dependent	NONE NONE

Vaginal	C-Section	VBAC
Spontaneous Labor	Induction using pitocin	Pitocin without induction
Epidural	Forcepts Used	Vacuum Extraction
IV w/Antibiotics	Anemia	Blood Loss
Blood Transfusion

Latch-on difficulties	Engorgement	Sleepy Baby
Sore nipples	Cracked/bleeding nipples	Preference to one breast
Breastfeeding refusal	Breast pain	Excessive crying
Baby always seems hungry	Low milk supply concerns	Over supply of milk
Baby slow weight gain	Milk never "came in"	Using nipple shield
Breast pump dependent	Other