Postpartum Client Intake Form

Contact Information

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First Name

Last Name

SMS Number

Address

Address 2

City

Zip Code

Pregnancy or Baby Info

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Baby's First Name + Last Initial

EDD or Baby's Birth Date

Baby's Gestational Age at Birth (Ex. 38 Weeks and 3 Days)

Baby's Birth Weight

Baby's Current Weight

Average Number of Wet Diapers Per Day

Average Number of Stool Diapers Per Day

What is the color and consistency of the stool?

What is your feeding method?

Primary Concern / Reason for Calling (Examples: latch issues, milk supply concerns, nipple pain, pumping questions, etc.)

Frequency of Nursing / Pumping

Duration of Nursing, Pumping or bottle feeding sessions? (Ex. R breast 20 minutes, Left breast 18 minutes)

How much milk is baby receiving per session (if bottle-feeding)?

How often is client expressing milk per day?

Parent’s Health History Relevant to Lactation (e.g., breast surgery, hormonal conditions, PCOS)

Baby’s Health Concerns (e.g., jaundice, tongue tie, allergies, prematurity)

Explain any complications that you have had with this pregnancy, any restrictions your provider has given you, and any medications (prescription or OTC) / natural supplements / vitamins you are currently taking.

Postpartum Support Questions

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Are you taking time off from work and if yes, how long?

Will you partner be taking off time from work and if yes, how long?

How do they feel about the new baby?

Please tell us the names and ages of any other children you have:

Are there any pets in your home and if yes, what kind?

Do you have any other adults living in your household?

Do you (or your family) have any history of depression or other emotional disorders?

Do you currently see a therapist or counselor?

Pediatrician’s Name

Pediatrician’s Phone

Sleep Support Questions

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What sleep challenges are you experiencing?

What are your sleep goals?

Lactation Questions

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How is your baby currently feeding (breast, bottle, formula, etc)?

What concerns are you experiencing? (latch issues, low milk supply, pumping schedule, nipple pain)

SUBMIT

Lactation Support