Name *

First Name

Last Name

Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of birth *

MM

DD

YYYY

What is your midwife/OBGYN's name? *

First Name

Last Name

What is your midwife/OBGYN's fax number?

(###)

###

####

Please indicate if you regularly consume or have plans to resume consumption of any of the following: *

Alcohol

Caffenine

Illicit drugs

Marijuana

Tabacco

Vape

None

Other

What is your current stress level? Low--I feel like I am coping as well as ever. High--I do not feel able to cope at all *

1

2

3

4

5

6

7

8

9

10

What is your current pain level? 0- I am not currently in pain. 10 - I am in the most pain I can imagine *

0

1

2

3

4

5

6

7

8

9

10

Please tell me about your plans to return to work. * *

I will not return to work

I am unemployed and looking for work

I work full time in a separate location

I work full time from home

I work part time in a separate location

I work part time from home

I work from home and at a separate location

I am self-employed

Have you discussed pumping at work with your employer? * *

Yes

No

I am concerned about continuing to breastfeed after I return to work

Tell me about your childcare plans (if applicable): *

Nanny

Daycare

Partner or family member will care for baby

I will bring my baby to work

Not sure

Other

If you are experiencing any of the following post-birth warning signs (check all that apply), call your care provider or emergency services immediately. *

I am not experiencing any of these warning signs

Shortness of breath

Seizures

Thoughts of hurting yourself or your baby

Sadness that lasts longer than 10 days

Bleeding that is soaking through one pad/hour

or with clots the size of an egg or larger

Incision that is not healing

Red or swollen leg that is painful to touch

Fever of 100.4° F or higher

Headache that does not improve after taking medicine

or that comes with vision changes

None

Please check any area where you have a current or chronic health condition *

Constitutional: headache - fatigue - insomnia -loss of appetite - current fever - birth trauma

Vision: dijculty seeing - eye pain

Ear/nose/throat: pain in ear/sinus/throat-runny or bleeding nose - ringing in ears

Cardiovascular: chest pain/shortness of breath (CALL YOUR DOCTOR IMMEDIATELY)

Respiratory: dijculty breathing (CALL YOUR DOCTOR IMMEDIATELY)

Gastrointestinal: indigestion/gas - hemorrhoids - constipation - diarrhea - pain in abdomen not related to birth

Genitourinary: incontinence - abnormal discharge - bleeding or clots after lochia has passed

Musculoskeletal: pain/stiffness - chronic arthritis

Breast: open wounds or lacerations on nipples - lumps that do not change in size - rash/eczema/other skin changes - breast/nipple pain when not feeding/pumping - open incision/drain - breast implants

Neurological: dizziness/fainting (CALL YOUR DOCTOR IMMEDIATELY)

Psychiatric: depression/anxiety that does not come and go - insomnia unrelated to newborn care - history of mental illness

Endocrine: excessive sweating - feeling too hot/too cold - excessive hunger/thirst unrelated to breastfeeding

Hematological/lymphatic: iuid retention - family history of hemophilia - anemia easy bruising

None

How would you describe your diet? *

Omnivore

Gluten-Free

Dairy Free

Vegetarian

Vegan

Primal

Paleo

Other

What changes have you noticed in your breasts? *

Grew larger

Sensitive nipples

Darker areolas

Leaking colostrum

Tenderness

Pain

Other

Please select any issues you had during your pregnancy: *

anemia

bed rest

cerclage

group B strep

gestational diabetes

high blood pressure

hyperemesis

infection

premature contractions

Other

Do you have any special circumstances? *

Planned induction

Planned cesarean

Multiple birth

Home birth

Birthing Center

Other

None