New Client Forms | Midwest Lactation Ll

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First name

Last name

Phone number

Mom's Birthday

Month

Day

Year

Medical Insurance

Support person

Address

Baby's name and gender

Baby's birthday and gestational age at birth

Place of birth

Type of delivery and experience

Birth weight

Discharge weight if remember

Most recent weight

Baby's medications &/or supplements

Mom's medications &/or supplements

Any known allergies

Referred by

Pediatrician Name

OB / Midwife Name

Number of children and previous breastfeeding experience

Any diagnosed medical condition? Mom and baby

Any challenges getting pregnant? If yes please explain

Any breast surgeries, biopsy? If yes, when and type of surgery

How often has baby nursed in last 24 hours?

Are you supplementing your baby with breastmilk or formula? If yes, how often and how much?

Number of wet diapers in last 24 hours?

Number of dirty diapers in last 24 hours? What color?

Do you have a breast pump? What kind is it?

Are you pumping? If yes, how often do you pump and how much milk are you typically able to express?

Please share the challenges you're experiencing and the goals you hope to reach.

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