Thank you for choosing our Lactation Counseling Services. This form will help us understand your feeding goals, any challenges you're experiencing, and how we can best support you.

Please complete this form as thoroughly as possible before your consultation.

Personal Information

Full Name: *
Date of Birth: *
Phone Number: *
Email Address: *
Emergency Contact Name & Relationship: *
Emergency Contact Phone Number: *
Baby’s Full Name: *
Baby’s Date of Birth: *
Baby’s Birth Weight: *
Baby’s Current Weight (if known): *

Birth & Medical History

How was your baby born? *
Did you experience any of the following during pregnancy or birth? *
Any known health conditions for baby? *
If yes, please specify: *
Any known health conditions for you? *
If yes, please specify: *
Are you currently taking any medications or supplements?
    If yes, please list:
*

Feeding History & Current Feeding Situation

What are your primary feeding goals? *
How often is your baby feeding? *
How long does a typical feeding session last? *
Are you offering both breasts at each feeding? *
Does your baby take a bottle? *
If yes, what type of milk?
Have you introduced a pacifier? *
How does your baby latch? *

Current Breastfeeding/Bodyfeeding Concerns

Are you experiencing any of the following challenges? (Check all that apply) *
If pumping, what type of pump are you using?
How often are you pumping?
How much milk are you able to pump per session (if applicable)?
Do you need guidance on bottle-feeding techniques or paced feeding? *

Maternal Wellness & Emotional Support

How are you feeling emotionally about your feeding experience so far? *
Do you feel you have enough support in your feeding journey? *
What has been the most challenging part of feeding so far? *
What has been the most rewarding part of feeding so far? *

Diet, Hydration & Lifestyle Considerations

Are you following a specific diet? (Check all that apply)
How much water do you drink per day? *
Do you consume caffeine? If yes, how much per day?
Do you consume alcohol? *
Do you take any of the following supplements or herbs?

Additional Questions & Support Needs

Are you interested in learning about: *
Do you have any specific questions or topics you’d like covered during your consultation? *
What are your top 3 goals for this lactation consultation?
    *

    Consent & Agreement

    I understand that Lactation Counseling is not a substitute for medical advice, diagnosis, or treatment. I acknowledge that this consultation is designed to provide education, support, and personalized strategies to improve my feeding experience.

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