Lactation Visit

Page 1 of 3 - Contact Information and History

33%
Name Name First Last
I would like to schedule a visit at

Breastfed Nola is located at 3915 Baronne St. All lactation appointments are private and you may bring any support persons you like. Free street parking is available.
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Phone Phone - ### - ### ####
Who is your pediatrician?
How old is your baby?
Tell us a little about what's going on
Do you have any history of

Do you have any history of thyroid condition PCOS or ovarian cysts Third option Diabetes type 1 Diabetes type 2 postpartum hemorrhage breast surgery breast cancer none of the above Other Other
Please list any current medications including herbs and supplements.
Have you breastfed before?
If you have breastfed before, tell us a little about your experience(s). How long did you breastfeed each child?
During your pregnancy, did you experience any of these?

During your pregnancy, did you experience any of these? breast enlargement breast tenderness darkening areola leaking or noticing dried colostrum on nipples
Any pregnancy complications?
At how many weeks gestation was your baby born?
During your labor did you receive or experience:

During your labor did you receive or experience: induction IV fluids epidural/spinal anesthesia antibiotics
How often is your baby eating?

Please estimate how many minutes or hours between feedings. For example, every 2 hours. Every 3 hours. Hourly. etc.
Approximately how long is each breast feeding?
Are you currently

Are you currently pumping bottle feeding syringe/finger/SNS feeding using a pacifier supplementing with your breastmilk supplementing with donor milk supplementing with formula
If you currently have a pump, what pump do you have?
Do you have

Do you have nipple pain pain with latch nipple cracks or other damage firm, sore lump in breast
Are you using any of the following?

Are you using any of the following? breast shells nipple shields tool to erect nipple pump to erect nipple
If supplementing:

If supplementing: supplementing before breastfeeding supplementing after breastfeeding baby is taking all nutrition from bottle or other means, not nursing at breast at all. supplementing once/day supplementing twice/day supplementing three times/day supplementing four or more times/day Other Other
If supplementing, how many oz/supplement?
If pumping, how often are you pumping?
If pumping, how many oz do you get?
What was your baby's birth weight?
Please list any other weights you know.

For example:
24 hour weight - 7lbs 8oz
7 day weight - 7lbs 3oz

Please answer the following questions about your baby's diapers, the best you can remember.
	today	yesterday	the day before	on average
1 poop	1 pooptoday	1 poopyesterday	1 poopthe day before	1 poopon average
2 poops	2 poopstoday	2 poopsyesterday	2 poopsthe day before	2 poopson average
3+ poops	3+ poopstoday	3+ poopsyesterday	3+ poopsthe day before	3+ poopson average
1-2 wet diapers	1-2 wet diaperstoday	1-2 wet diapersyesterday	1-2 wet diapersthe day before	1-2 wet diaperson average
2-3 wet diapers	2-3 wet diaperstoday	2-3 wet diapersyesterday	2-3 wet diapersthe day before	2-3 wet diaperson average
4+ wet diapers	4+ wet diaperstoday	4+ wet diapersyesterday	4+ wet diapersthe day before	4+ wet diaperson average
no poop	no pooptoday	no poopyesterday	no poopthe day before	no poopon average
no wet diapers	no wet diaperstoday	no wet diapersyesterday	no wet diapersthe day before	no wet diaperson average

My baby's poop is

My baby's poop is dark and tar-like green yellow (mustard) has 'seeds' or 'curds' in it completely absorbed by diaper
What is your baby feeding goal?
With permission, we sometimes take pictures to share on social media. These are not necessarily breastfeeding images and you will have opportunity to approve of an image before it is shared. You can review our instagram accounts @nolanesting and @breastfednola to see the types of images we share. Do we have your permission to share a picture from our session?
How did you hear about us?
$0

Total

+Tax 3%

Lactation Visit

Lactation Visit

Page 1 of 3 - Contact Information and History

$0

Total

+Tax 3%

$`0`