Mother's Name *

Age *

Date of Birth *

Address *

City *

Zip *

Email Address *

Home Phone

Cell/Work Phone

Baby's Name *

Age *

Date of Birth *

Breast / Nipple Pain   Poor Nursing   Slow Gain   Other  

Who else is helping with problem ?

Mother's OB / PCP *

Baby's Ped / P CP *

Mother's Doctor Phone # *

Mother's Doctor FAX #*

Baby Doctor Phone # *

Baby Doctor FAX #*

Other children, ages, duration of BF

Family BF
Mother
Sister
Breast Surgery

Allergy
Mother
Sister
Siblings

Recent illness / injury / surgery other than births

Chronic Illness Yes

Depression Yes

Abuse Yes

Eating Yes

Abortion Yes

Smoke Yes

Alcohol Yes

Caffeine Yes

Dairy Yes

Other Dietary Yes

Medications incl. Vitamins Yes

Pregnancy Planned Surprise Fertility

Pregnancy Problems

Breast Change Yes

Yeast Infection Yes

Toxemia / HBP Yes

Weight Gain Yes

Feelings About Pregnancy

Labor @ Week

Induced Yes

Baby Problems Yes

Epidural @ cm

Other Meds

Quality / length

Vaginal Forceps Cesarean

Feelings about labor and birth

APGARs

Birth weight

1st Nursing

1st Day Pattern

Separation Yes

Supplements Yes

Pacifier Yes

Jaundice Yes

Copious Milk Yes

Engorged Yes

Nipple Pain Yes

Baby Sick Yes

Circumcised Yes

Pumped Yes

Alternate Feeds Yes

In - Hospital BF

BF Times A Day

Average Length

Who Ends

Time Between

Quality

Longest Sleep

Longest Sleep

# Wet / 24 hr

# BM / 24 hr

Color

Quantity

Fussy Yes

Alert/Calm Yes

Sleepy Yes

Other Yes

Father's feelings

Calm Yes

Chaotic Yes

Help at Home Yes

Relatives / Visitors Yes

Mixed Advive Yes

Money Problems Yes

Back to Work Yes

BF Support Yes

Mothers Breast Feeding Goals

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