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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

Client Information- MOTHER

Emergency Contact Information

Client Information- Infant

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 *
 

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? *

Social History

Marital Status *
Do you have help at home? *
Smoking History *
Alcohol consumption *
Attended Breastfeeding Class *
Attended Childbirth Class *
Previous Pregnancies? *
Previous Births? *

About your current birth

Was this baby premature? *
Type of birth and interventions or complications *
Complications after delivery? *

Tell me about your breastfeeding experience so far

Are you experiencing- Check all that apply *