MATERNAL HISTORY (Check all that apply)
_____________________________________ ___/___/___
Name
MATERNAL HISTORY:
Do you have any allergies? ___NO: ___ YES:
Please list
_________________________________________
Are you taking any medication? ____ NO: ___ YES:
Please list:
________________________________________
Have you ever had or been diagnosed with any of
the following?
___ Abnormal pap smear ___ Allergy
___ Asthma
___ Anemia
___ Cancer
___ Constipation
___ Depression
___ Diabetes
___ Diarrhea (chronic)
___ Heart disease
___ Hemorrhoids
___ High blood pressure
___ Infertility
___ Kidney disease
___ Thyroid disorder
___ Venereal disease
___ Tuberculosis
___ Yeast Infection
___ Vaginal herpes
___ PCOS
___ Liver disease (Hepatitis)
___ None of the above
___ Other:
_________________________________________
Have you ever been diagnosed with Raynaud’s?
___ NO ___ YES
Have you been diagnosed with HIV?
___ NO ___ YES
Have you had any of the following?
___ Breast surgery
___ Breast augmentation
___ Breast reduction
___ Breast biopsy
Have you had Botox injections for treatment of
underarm perspiration? YES or NO
Have you ever been diagnosed with mastitis?
When? ___________________________________
Treatment?________________________________
PERINATAL HISTORY:
How many times have you been pregnant? ______
How many living children do you have? _______
Did you have any of the following during this
pregnancy?
___ Anemia
___ Fever
___ High blood pressure
___ Nausea/vomiting
___ Premature labor
___ Gestational diabetes
___ Infection -Treatment?:_______________
___ None of the above
___ OTHER:
________________________________________
Date
Did you attend prenatal childbirth classes (Lamaze,
Bradley, etc)? YES or NO
If yes, who was your instructor?
_______________________________________
Gestational Age: how many weeks pregnant were
you when you gave birth to this baby?
_________ weeks
Did you have any of the following during your labor
and birth?
___ Drugs to induce or speed labor (Pitocin): If yes,
for how long during labor was the drug
administered? ___________hours
___ Premature rupture of membranes
___ Antibiotics
___ Fever
___ Hemorrhage
___ High blood pressure
___ None of the above
Did you have a vaginal or cesarean birth?
____ Vaginal
____ Cesarean
Did you have any of the following pain medications
during labor and birth? If yes, how long before birth.
___ Stadol: ____hr.
__ Demerol: _____hr.
___ Local: _____ hr.
__ Spinal : _____ hr.
___ Epidural: ___ hr.
___ General:_____________
___ Other: _______________________________
___ None of the above.
With this labor and birth did you have any of the
following?
___ Episiotomy
___ Breech presentation
___ Tear
___ Forceps
___ Vacuum extraction
___ Total labor longer than 30 hours
___ Pushing stage longer than 2 hours
___ None of the above
Did you experience any of the following postpartum
complications?
___ Urinary/other infection
___ Fever
___ Excessive bleeding
___ High blood pressure
___ Low blood pressure
___ Head ache
Are you currently having vaginal bleeding?
___ NO
___YES
Have your menstrual periods returned?
___ NO ___ YES; Date of last period:
____/_____/____
Are you using any form of birth control now?
___ NO ___ YES
If yes, what form(s)?
__________________________________________
PLEASE CONTINUE ON NEXT PAGE
FEEDING HISTORY:
How soon after birth did you put your baby to breast?
__ < 30 minutes
__ 30 minutes to 1 hour
__ > 1 hour
__ Other: ____________________________
Were you and your baby separated for more than 2
hours while in the hospital? ___ NO
___ YES
While in the hospital, how many times in 24 hours
did you breastfeed your baby?
___ Less than 8 times
___ 8 - 12 times
___ More than 12 times
While in the hospital, did you experience any of the
following?
___ Attachment difficulties
___ Sleepy baby
___ Engorgement
___ Sore nipples
___ Baby preferred one breast
___ Not enough milk
___ None
___ Other:
___________________________________
While in the hospital, was your baby given any
supplements?
___ Pumped mothers milk
___ Water
___ Artificial formula
___ Glucose water
___ None
If supplemented, how were supplements given?
___ Bottle
___ Syringe
___ Dropper
___ Cup
___
Other:_____________________________________
How long does your baby nurse at each breast:
___________min.
Who decides when the feeding is over?
___ Mother
___ Baby
___ Varies
At home, has your baby received any of the
following:
___ Water
___ Formula
___ Liquids, other than formula
___ Any solids
___ None of the above
If your baby has received any supplements, how
were they given?
___ Bottle
___ Syringe
___ Dropper
___ Cup
___ Other:
__________________________________________
How many times last 24 hours has your baby had:
# OF WET DIAPERS: ___________
# OF BOWEL MOVMENTS: _____________
What is the color and consistency of your baby’s
bowel movements?
___ Yellow
___ Green
___ Brown
___ Tar like
___ Soupy/seedy
___ Liquid
___ Other:
__________________________________
Does your baby spit up?
___ Never
___ Occasionally
___ Often
Is your baby content or sleepy between feedings?
___ Never
___ Occasionally
___ Often
While in the hospital was your baby given a pacifier?
___ NO
___ YES
Has your baby had any prolonged crying spells?
___ Never
___ Occasionally
___ Often
Did you and your baby go home at the same time?
___ NO
___ YES
Is your baby given a pacifier?
___ Never
___ Occasionally
Have you used any of the following?
___ Breast shells
___ Breast pump: ___________________________
___ Breast/ Nipple cream: ____________________
___ Nursing bra (with under wire)
___ Nursing bra (no under wire)
___ Nipple shield
FAMILY HISTORY:
Does anyone on either side of the baby’s family have
any of the following?
___ Food allergy
___ Asthma
___ Eczema
___ Hay fever
___ Thyroid disease
___ Cancer (breast)
___ Diabetes
___ Genetic disease
___ Gastrointestinal Reflux (heart burn)
___ None of the above
___ Other:
__________________________________________
CURRENT FEEDING HABITS:
How does your baby signal he/she is ready to feed?
How many times in 24 hours are you breastfeeding
your baby?
___ Less than 8 times
___ 8 - 12 times
___ More that 12 times
What is the longest time between feedings?
DAY: _________ hr. NIGHT: ____________ hr.
___ Often
PLEASE CONTINUE ON NEXT PAGE
When did you decide to breastfeed this baby?
___ Before pregnancy ___ During Pregnancy
___ After giving birth
How did you prepare for breastfeeding?
___ Childbirth Classes
___ Breastfeeding Classes
___ None of the above
Other:__________________
LIFESTYLE:
Do you feel you are getting enough rest?
___ Never
___ Occasionally
___ Regularly
Have you breastfed previous children? ____ NO
___ YES: If yes, for how long? ________________
Why did you stop?___________________________
For how long do you plan to breastfeed this
baby?_____________
How often are you drinking beer, wine, hard liquor, or
mixed drinks? ___ Daily ___ Weekly ___ Monthly
___ Never
How many cigarettes do you smoke each day?
___ Do not smoke
___ Less than 10
___ 11 - 20
___ More than 20
Why do you think you will stop breastfeeding at that
time? ____________________________________
Additional Permission Request & Information
NUTRITION:
Are you on any special diets?
___ High protein
___ Low salt
___ Low fat
___ Diabetic
___ Weight loss
___ No special diet
If yes, who suggested the diet?
__________________________
Are you trying to lose weight at this time?
___ NO
___ YES
If yes, how much? _________________
How?
___ Less food
___ Exercise
___ Other:___________
For educational purposes and record keeping the
lactation consultant may ask for photos/videos as
part of the consult with your permission.
Photo of baby’s latch:
___ yes ___ no
Photo of baby’s mouth: ___ yes ___ no
Photo of nipple/breast condition: ___ yes ___ no
I give my permission for a student lactation
consultant to observe my consultation.
___ yes ___ no
An Initial In-Home Consult is $125 and an In-home
Follow-up Consult is $100.

Are there any foods that you avoid eating?
___ NO___ YES; What?______________________
24-hour notice is needed to cancel or
reschedule appointment OR a $25 fee will
be charged.
SIGN: ____________________________________
Why?_____________________________________
Are you a vegetarian?
___ NO
___ YES
How would you rate your appetite presently?
___ Good
___ Fair
___ Poor
THANK YOU
Your Babyology Staff
Do your have some one to help you shop and
prepare meals?
___ NO
___ YES
VAS 3/15