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MotherBorn LLC 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
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Appointment Date
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Appointment Time
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Client Information- MOTHER
Mother's First Name
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Middle Initial
Mother's Last Name
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Street Address
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Street Address 2
City
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State
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Zip Code
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Preferred Phone Number
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Phone Type
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Home
Cell
Alternate Phone
Mother's Email Address
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Mother's Date of Birth
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Insurance Carrier for Mother
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Insurance ID (Aetna/Blue Cross Plans/ Keystone - Card must be presented during appointment
Full Name of Policy Holder (self, spouse, etc)
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Date of Birth of Policy Holder
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OB/Midwife Practice Name
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OB/Midwife at Delivery Name
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OB/Midwife Address- City Only
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Hospital/Birth Facility
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Emergency Contact Information
Name of Emergency Contact Name (husband/partner/mother/father/friend
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Phone Number of Emergency Contact
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Type of contact:
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Husband
Partner
Mother/Father
Friend
Other
Client Information- Infant
Infant's First Name
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Middle Initial
Infant's Last Name
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Infant's Date of Birth
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Infant's Birth Weight
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Infant's Discharge Weight
Pediatric Practice Name
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Pediatric Address- City Only
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Last Pediatrician Seen
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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)?
Client History Form (Mother)
Mother- Past Medical History: Do you have now or ever had? If NONE check NONE
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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
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
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Excessive/Quick Weight Loss
Fevers
Chills
Poor appetite
Fatigue
Insomnia
NONE
Skin
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Rash
Pups Rash
Hives
Hair Loss
Skins sores/ulcers
Itching
NONE
Musculoskeletal
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Joint Pain
Muscle Aches
Leg or Arm cramps
Back Pain
Muscle Weakness
Bone Pain
Joint Swelling
NONE
Psychiatric
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Anxiety
Depression
Baby Blues
Panic Attacks
Suicidal Thoughts
Use of Antidepressants
Alcohol or Drug Dependence
NONE
Endocrine
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Thyroid issues
Use of Thyroid Meds
Reynaud's
Cold intolerance
PCOS
Infertility
NONE
Allergy/Immunology
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Allergic Reactions
Yeast infections (prone?)
Hepatitis
HIV Positive
Other- list in comments section
NONE
Breast Conditions
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Fibrocystic
Breast Assymmetry
Breast Implants
Breast Reduction
Biopsy
Nipple Piercing
Past Chest Surgery/Trauma
NONE
Are you allergic to any medications?
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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
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Spouse
Partner
Single
Do you have help at home?
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Yes
No
Smoking History
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None smoker
Current smoker
Ex smoker
Alcohol consumption
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Never
Occasional
Frequent
Attended Breastfeeding Class
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Yes
No
Attended Childbirth Class
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Yes
No
Previous Pregnancies?
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Yes
No
Previous Births?
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Yes
No
Previous breastfeeding length?
About your current birth
Was this baby premature?
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Yes
No
Gestational Age of Baby?
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Type of birth and interventions or complications
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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
Any stressful complications?
Complications after delivery?
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Jaundice
Jaundice with light therapy
Trouble Breathing
Low blood sugars
Temperature issues
NICU
NONE
Enter any additional comments here:
Tell me about your breastfeeding experience so far
Are you experiencing- Check all that apply
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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
Please list other issues or concerns here:
Please list other issues or concerns here:
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