Please fill out the following form to help us understand your history and goals.
Please provide point-form details for each issue above.
Baby's age & adjusted age (preemie) (baby 1, baby 2)
Birth pregnancy postpartum issues/trauma/
# of feeds in past 24 hrs
How many from:
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Breast/chest
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Bottle (my milk)
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Bottle (donated milk)
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Bottle (formula)
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Supplemental Nursing System
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Spoon feeding
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Cup feeding
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Syringe Feeding
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Combo (e.g. SNS or syringe used at breast/chest)
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Is baby being given water or other drinks besides milk or formula?
Is baby being given food other than milk or formula?
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If you are breast/chest feeding:
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does one side produce more than the other?
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do you finish one side completely then switch to the other side?
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What is your baby like after feedings?
Very limp, with floppy limbs
Sleepy
A little sleepy
Deeply sleepy
Asleep
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What are your baby's feeding cues?
Can you feel or otherwise notice your letdown? (yes, no, I don't know, what is letdown)
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Baby's behaviour when starting a feed:
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Eager
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Desperate
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Shaking head side-to-side
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Crying
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Gape (mouth): Tiny, Middling, Pretty wide, Very wide
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Calm
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Sleepy
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Waking baby to feed?
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Avg nursing time
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Hrs between daytime feeds
Hrs between nighttime feeds
Using pacifier?
Wet diapers in the last 24 hrs:
Diapers with stools:
Maternal appetite:
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Have you seen any other healthcare professionals about these or other feeding issues?
If yes, what instructions did they give you?
Was baby separated from breast/chestfeeding parent (taken somewhere that the parent and baby could not connect in any way)?
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Current infant weight:
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What is your overall impression of your current feeding situation?
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Thanks for completing your intake.
