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Maternal-Infant History Form

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Please fill out this form entirely. All information is strictly confidential.

Mother’s Name:

Email Address (REQUIRED)

Please make sure that this is the same e mail address as the one on your PayPal Account.

Mother’s Age:

Baby’s Name:

Baby’s Age:

Maternal History

Are you in good health?

Yes    No 

If not, please describe any medical problems:

Are you taking any prescription or non-prescription medications (inc. birth control pills or shots, vitamins, or herbs)?

Yes    No 

If so, please list:

Do you smoke cigarettes?

Yes    No 

If so, how many per day?

Do you drink caffeinated beverages (coffee, tea, soda)?

Yes    No 

If so, what type and how many ounces per day:

Do you drink alcohol?

Yes    No 

If so, what type and how many ounces per day/week?

Did you take any medications during pregnancy?

Yes    No 

If so, please describe:

Have you ever had any type of breast surgery?

Yes    No 

If so, please describe:

Were your breasts examined during your pregnancy? Were any problems noted (asymmetry, flat or inverted nipples, etc)?

Yes    No 

If so, please describe:

Do you have any allergies?

Yes    No 

If so, please describe:

Did you notice any breast changes during pregnancy?

Yes    No 

Please describe:

Is this your first baby?

Yes    No 

If no, please supply the following information:

Age  --  Breastfed?  --  How Long?

1st (oldest) child:

2nd child:

3rd child:

4th child:

5th child:

6th child:

For this baby and any other babies you nursed, did your milk “come in” by the third day after birth?

Yes    No 

If this is not your first breastfed baby, describe any breastfeeding problems you experienced with previous babies:

Are you currently on a restricted diet of any kind (vegetarian, weight loss, low sodium)?

Yes    No 

If so, please describe:

When did you decide to breastfeed this baby?

Select Before Pregnancy Early Pregnancy Late Pregnancy After Baby's Birth

How long do you want to breastfeed?

Select Up to 6 weeks Up to 3 months Up to 6 months Up to 1 year Until baby weans Other (specify)   

When your baby nurses, what do you feel:

Select Tingling Warmth Filling Burning Leaking on other side Nothing Other (describe)

Have you ever experienced:

Sore nipples:

Yes    No 

Plugged duct:

Yes    No 

Breast infection:

Yes    No 

Severe engorgement:

Yes    No 

A feeling of being “softer” after a feeding:

Yes    No 

Discomfort from fullness in the breasts:

Yes    No 

Birth History

Type of delivery:

Vaginal    Cesarean 

Why?

How long was your labor?

Were medications given during labor or delivery?

Yes    No 

If so, what kind?

Were medications given after the birth?

Yes    No 

If so, describe:

Was it a difficult birth?

Yes    No 

If so, describe:

Place of birth:

Home   Hospital    Birth Center 

Rooming in 24 hours per day?

Yes    No 

Were you separated from your baby for any length of time soon after birth?

Yes    No 

If so, why?

Infant Feeding History

How long after the birth was baby put to breast?

Did baby take to nursing easily?

Yes    No 

Has your baby received any bottle feedings?

Yes    No 

If so, when and why?

What type of bottle and nipple was used?

What was in the bottles?

Breastmilk   Formula   Other 
What? 

Have you expressed breastmilk?

Yes    No 

If yes, using which method?

Brand and Type of Pump: 

Does your baby take both breasts at feeding?

Yes    No 

What nursing position do you use?

Select Cradle Football (clutch) Hold Lying down Other

How long on each breast at each feeding?

How long does each feeding last (average)?

How many feedings in 24 hours (inc. snacks):

Select Less than 6 6-8 8-10 More than 10

Do you hear baby swallowing during feedings?

Yes    No 

Does your baby end the feeding or do you?

Select Baby Ends Feeding I End Feeding

Is your baby satisfied at end of feeding?

Yes    No 

Does your baby pause often during feeding?

Yes    No 

Does baby make clicking sounds while feeding?

Yes    No 

Does your baby burp easily?

Yes    No 

Does you baby spit up after feedings?

Yes    No    How Often?

Do you use disposable diapers?

Yes    No 

How many wet diapers does your baby have each 24 hours?

How many bowel movements does your baby have each 24 hours?

Consistency? -- Color?

Describe your baby’s attitude:

Select Fussy Active Placid Colicky Average

Do you use a pacifier?

Yes    No 

If so, what type, and how often?

Does your baby suck his thumb or fingers?

Yes    No    How often? 

Does your baby eat any solid foods?

Yes    No 

If so, describe what foods, when started, and how often:

Baby’s Medical History

Baby’s expected due date:

Baby’s actual date of birth:

Baby’s birth weight:

Baby’s other weights:

Baby’s current weight:

Were there any problems with the baby immediately after birth?

Yes    No 

If so, please describe:

Has your baby had any medical problems since birth?

Yes    No

If so, please describe:

Was your baby jaundiced? If so, what was your baby’s peak (highest) bilirubin level?

Yes    No   

Was your baby put under bililights?  For how long?

Yes    No   

Is your baby currently taking any medications?

Yes    No 

If so, what kind, what dosage, and why?

Is baby currently taking vitamin supplements?

Yes    No 

If so, what kind?

Please state your question(s) below along with any other information you feel that would be helpful to me. Thank you!

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