BREASTFEEDING FIXERS
JAMES G. MURPHY, MD, FAAP, FABM, IBCLC
509 S. Cedros Ave, Suite D, Solana Beach, CA 92075-2900
Appointment Date: ___________________________ Time:____________
Infant’s Name (First Last):_____________________________Sex: M F DOB__________
Gestational age at birth: _______weeks, _______days
Birth Weight________24 hour weight_______ Lowest weight____________
Mother’s Name (First Last):_______________________________DOB_________________
Mother’s Cell Phone#:________________________________________________________
Mother’s Email:______________________________________________________________
Mother’s Address____________________________________________________________
Father’s Name (First Last):____________________________________________________
Father’s Cell Phone#:
____________________________________________________
Pediatrician:__________________________
IBCLC:_____________________________
Who referred you to our practice:_____________________________________________
Ethnicity: a. Hispanic/Latino b. Asian/Pacific Islander c. Other:__________________
Preferred Language: a. English
b. Other: _____________________________________
Race: ____________________________________________________________________
About This Pregnancy
Did you need Medical intervention to get pregnant? If yes, what________________________
Was this your first pregnancy?: Yes No
If no, How many pregnancies:_____________
How many children?:_____________Did you breastfeed your other child(ren)?:___________
Longest previous breastfeeding experience?:_____________________________
Which family planning methods are you planning on using? Norplant Depo shot Barriers
Mini pill Vasectomy tubes tied
natural family planning/rhythm
none
Did mom have breast/nipple changes during pregnancy?: Yes
If not, have they enlarged since delivery?:
Yes
No
No
Was the delivery: Vaginal C-Section Vacuum Forceps Pitocin induced Spinal/Fentanyl
Were there problems with the delivery?: No. Yes (please explain):____________________
Have you had any breast surgery?
No
Yes: Nipple Piercing: Right Left
Breast implants
Breast reduction Year done_____ Where is the incision _____________
Cup size before surgery __________ Cup size after surgery_________________
Have you had any of the following procedures related to your breast: lumps biopsy
fibrocystic disease piercing,year done_______ Right Left
Nipple involved? No Yes
During this pregnancy have you had?: premature labor gestational diabetes depression
High blood pressure anemia fever urinary tract infection placenta previa preeclampsia
Did the baby have any of the following after birth?: NICU hrs______days______
breathing difficulties Low blood sugar meconium aspiration deep suctioning
irregular heart rate
jaundice: Highest bili________
Is mom on any medications? No Yes If yes, what__________________________________
Is baby on any medications? No Yes if yes, what_________________________________
Breastfeeding:
Exclusively breastfeeding
Supplementing:
No
Yes
Pumped Breastmilk
Shared Breastmilk
Formula
Every feeding OR about #______feedings each day.
How is this being given?:
plastic tube at the breast
finger feeding
Do you need a nipple shield to nurse?: Yes
With this baby, have you had:
No
syringe only
No.
Yes/ Right
Yes / Left
Yes, Both
Nipple bleeding?:
No
Yes/ Right Yes / Left
Yes, Both
Scabs?:
No
Yes/ Right
No
Yes / Right Yes / Left
Yes/ Left
Red Swollen Nipples after nursing?
No
slow-flow bottle
Never used one
Nipple cracks?:
Open sores or missing pieces?:
cup
Yes, Both
Yes, Both
Yes
Have your nipples been flattened or creased after nursing?:
Yes
Nipples post feed are white or purple with vasospasm?: Yes
No
How long does it take to latch to the breast without using a nipple shield?:
Right: ___________ Left _____________
And with a nipple shield?: Right:___________ Left___________ N/A
No
How long is a typical breastfeeding?: ___________________
How long does your baby sleep between feedings?: Day ____________Night____________
Does the baby make a clicking sound during nursing?:
Does your baby fall off the nipple?:
No
No
Sometimes
Sometimes
Often
Often
What nursing position have you been using?:
Cradle
Cross-cradle Football
Side Lying
Are Feedings?: Demand (as baby requests)
If scheduled, how often:_________________
Are you pumping?: No Yes I am using: Manual Pump
Single Electric Pump
Double Electric Pump
Hospital grade pump
Used pump
How often do you pump?: ________________I began pumping when my baby was _____
days / weeks old
Each time I pump I get about the following number of ounces: right _________ left_________
Do you take any Herbs for your milk production?:
No
Yes, I take:
Fenugreek Goat’s Rue More Milk Plus Malunggay Mother’s Milk Tea Other__________
In the last 24 hours my baby has had __________ wet diapers
In the last 24 hours my baby has had __________ poops that were bigger than a half dollar.
The color of the last poop:
Black Dark Green Yellow-Green
Mustard
Has anyone found a Tongue Tie or Upper Lip Tie in your baby?: No Yes, who found it?:
Lactation in Hospital Private Practice Lactation Doctor Other:______________________
Is there a family history of Tongue Tie on either side of the family: No Yes: Who__________
Have you seen your infant extend the tip of the tongue out ½ inch past the lower lip?: Yes No
Does baby tongue thrust?: Yes
No
Does baby snore/grunt while lying on babies back?:
Yes
No
Does milk leak out from your infant’s mouth while nursing?: Yes
While bottle-feeding?:
Yes No
No
Is there a Family History (either side) of a Bleeding Disorder of any kind?:
No Don’t know Yes, Who:
Is there anything else you would like us to know about your breastfeeding experience with
this infant? If so, please comment here: