To make the most of your appointment, please fill out this form to the best of your ability. We can discuss further at your appointment if anything needs clarification.

Please also download the HIPAA notice for your review and fill out the Consent & Financial Agreement Form before your appointment and bring with you.

Having trouble with the online form?

Please note: a $50 non-refundable fee is required to secure your appointment time and cover the initial phone consultation and prep work for our appointment. If you need assistance submitting your $50, please contact me and I would be happy to help you!

Mother's Name:*
Mother's E-mail:*
Mother's Phone:
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Mother's DOB:*
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Infant's Name:*
Infant's DOB:*
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In your own words, describe any feeding problems that concern you:

Family History


Does anyone on either side of the baby's family have any of the following:
Other family history:
Was this your first pregnancy?
If no, how many pregnancies?
How many children?
Did you breastfeed your other children?
If so, how long?
Which of the following family planning methods do you plan to use?
Will you be returning to work?
If so, when? Full or part time?
Anyone in your home smoke?
Are you a vegetarian?
Do you drink?

Pregnancy & Birth History


Does your baby have any health problems?
Is your baby currently on any medications?
Are you taking any of the following?
Other medications/supplements:
Have you ever had any of the following procedures related to your breasts?
Other breast procedures:
Do you presently have or have you ever had any of the following?
Other issue:
Did you have any of the following during this pregnancy?
Other pregnancy issues:
Did you have any of the following during this labor and delivery?
Other labor and delivery issues:
If drugs were used to induce, how long was this administered? (hours)
If hemorrhage occurred, how much blood was lost? (pints)
What type of delivery did you have with this birth?
Gestational age of baby at birth:
Birth weight:
24hr. weight:
Present weight:
Did you have any of the following with this birth?
Other issues during birth:
Did you experience any postpartum complications?
Other postpartum issues:
Did your baby have any of the following after birth?
Other issues after birth:
If jaundiced, highest bili level:
What was your bra size?
Before pregnancy:
Now:
Changes since the birth?

Breastfeeding History


How old was your baby when you first realized that you were having breastfeeding difficulties?
Have you used any breastfeeding supplies?
If you used a pump, what type of pump?
Has your baby been supplemented with any of the following?
If artificial infant milk was used, what type? (formula)
If so, how was the baby supplemented?
Type of bottle nipple:
If supplements have been used, how often in the past 24 hours?
How much per feeding?
How many times in the past 24 hours have you breastfed your baby?
Are your experiencing any of the following?
Other breastfeeding issues:
Is the baby content or sleeping between feedings?
What is the longest time your baby has gone between feedings?
Day:
Night:
Who decides when the feeding is over?
How long does baby nurse at breast?
Nurses from:
Are you presently using a pacifier?
How often?
In the past 24 hours, how many:
Wet diapers:
Stools:
Were the stools bigger than a tablespoon?
How long do you wish to breastfeed your baby?

When submitting this form online, you will be asked to pay the $50 deposit and will be redirected to PayPal after submission. If you need to send in your deposit in another form of payment, please contact me.

Booking Fee:*

By submitting this form, I agree to pay a $50 non-refundable fee to hold my appointment time, or fail to attend my appointment.