Did you want the electronic intake forms?

If you prefer to use the electronic intake forms, click here to be taken to the instructions


otherwise, the questions for the consult can be found below.  Please email them to gaildittes@breastfeedinghelper.com

Questions for the Consult

Demographics

1. Your full name and date of birth


2. Your insurance company name; ID number; who is primary insured. (you? your spouse, your parent?)  If not you, I will need the full name and date of birth and address if different from yours.

*note, if you have two insurance plans, I will need to know all the details of each as well as WHICH ONE is considered the primary and which one is considered the secondary plan


3. Your address and parking instructions 

*note travel greater than 15 miles each way will incur a $25 out of area convenience fee which is NOT reimbursed  by insurance. cash or check is fine


4. your phone number and email address


5. Who can I thank for the referral? How did you find me?


6.  Your OB/Midwife name with practice location or a phone number



Your Medical History

7. Any medical conditions that you have and any medications that you take 


8. Allergies


9.  Special Diet?  Smoker?  Consume alcohol or caffeine?


10.  Are you taking birth control?  Do you plan to add or change birth control while breastfeeding?


11.  Did you have trouble conceiving? Did you have to take medication to sustain pregnancy?


12.  Were you ever tested for Diabetes or Thyroid ?



Pregnancy and Delivery Details

13.  How many pregnancies?  


14. Do you have other children? Did you breastfeed and for how long?


15.  Did any of these occur during your pregnancy:  Anemia; +GBS; Gestational diabetes; high blood pressure; urinary infection; premature labor; other (please list)


16.  Did your breasts increase in size  during puberty; pregnancy; and after delivery? (a lot? a little?)


17.  Did any of these occur during this labor and delivery:  antibiotics; artificial rupture of membranes; breech presentation; cord prolapse; drugs to control high blood pressure; epidural; episiotomy or tear; failed forceps; failed vacuum; fever; placental abruption; premature rupture of membranes; pushing greater than 2 hours;  drugs to speed up labor; excessive blood loss; other (please list) or none of the above


18.  Type of delivery:  Vaginal; VBAC; planned C-section; unplanned C-section; Emergency C-section


19.  Location of delivery

infant details

20.  Your baby's full name and date of birth and gender


21.  Your baby's birth weight and any weights done since then (including dates)


22.  Your goals for breastfeeding


23.  Any health issues experienced by baby immediately after birth and since then


24.  Your Pediatricians name and a phone number or location address


25.  How is breastfeeding going?  What is the reason for the consult request?


26. Anything else you think I should know



PLEASE EMAIL YOUR ANSWERS TO:  GAILDITTES@BREASTFEEDINGHELPER.COM