Pre Consult Questionnaire Email * Mother's Name First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Mother's Date of Birth Baby's Name First Name Last Name Baby's Date of Birth MM DD YYYY Reason for Consult Breastfeeding Goal Birth Weight Week's Gestation Current Weight Current Weight Date MM DD YYYY In the past 24 hours: How many times has baby breastfeed? Approximately how long does baby feed? In the past 24 hours: What volume (how many bottles) of formula has baby received? What Breastfeeding Positions have you tried Cradle Side-lying Cross Cradle Rugby/Football Reclined Does baby take a pacifier or use a nipple shield? Current Medications Medical or Surgery History (Mother) Have you breastfed before? Did you have any delivery Complications? What type of Pump are you using? How often are you pumping? How much volume do you express from each breast at each pumping session? How did you hear about International Lactation Support? Thank you!
