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MotherBorn Lactation Services

Dana L. Ehman BA, IBCLC, RLC

790 East Market Street, Suite 195

West Chester, PA 19382

www.motherborn.com

dana@motherborn.com

610-299-1038

Today's Date *

Appointment Date *

Appointment Time *

Client 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 during appointment

Relationship to Insured (Aetna/Blue Cross Plans/ Keystone)

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

OB/Midwife Practice Name *

OB/Midwife Address- City Only *

Hospital/Birth Facility *

Due Date *

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

What is your primary goal for our visit?

Do you have any major concerns about breastfeeding?

Client 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:

About your current pregnancy

Attending(ed) Childbirth Class *

Yes

No

Attending(ed) Breastfeeding Class *

Yes

No

Previous Pregnancies? *

Yes

No

Previous Births? *

Yes

No

Previous breastfeeding length?

Have you had breast changes during pregnancy? *

Yes

No

Any stressful complications?

Enter any additional comments 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

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