"*" indicates required fields Mom’s Name* Mom’s Age:*Mom’s Age:*Mom’s Cell Phone*Mom’s Address:* How would you describe your current health?*How were those children fed though their first year?*How would you describe your current diet?*What medications are you currently taking?*Please list any allergies that you have?*Please describe your pregnancy history?*Please describe your breastfeeding history?*Are you pumping? If so, what breast pump and flange size are you using? When do you pump?*Baby’s Name* Baby’s Due Date* MM slash DD slash YYYY Baby’s Date of Birth* MM slash DD slash YYYY Baby’s Age Today*Baby’s Birth Weight* Last Weight Date & Weight* Currently, is baby consuming breastmilk or formula or a mix of both?* How is baby consuming the above? (Breast, bottle or both)* Is baby eating any solids? If so what and how often?*Please list any known medical issues for baby*Who is baby’s primary care giver?* Your email* Consent* I have read and understand the Lactation Educator liability and disclaimer.
