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MotherBorn Lactation Services
Dana L. Ehman BA, IBCLC, RLC
790 East Market Street, Suite 195
West Chester, PA  19382

Client Information- MOTHER

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 *

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? *

About your current pregnancy

Attending(ed) Childbirth Class *
Attending(ed) Breastfeeding Class *
Previous Pregnancies? *
Previous Births? *
Have you had breast changes during pregnancy? *

Social History

Marital Status *
Do you have help at home? *
Smoking History *
Alcohol consumption *
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