First Name

Last Name

What type of birth experience did you have? What type of birth experience did you have? Vaginal Birth C-Section

Please describe your birth experience. If you've had a C-section, please explain why?

Was there trauma to you or baby? Was there trauma to you or baby? Yes No

If there was trauma, please explain:

If yes to any of the following, please explain: If yes to any of the following, please explain: Difficulty getting pregnant Infertility treatments Loss of previous pregnancy Depression Allergies Breast surgeries Eating disorders

Please explain:

Any medical conditions in you or your family? Any medical conditions in you or your family? Yes No

If yes, please explain medical conditions:

Are you or baby taking medications? Are you or baby taking medications? Yes No

If yes, please list medications:

Are you taking vitamins/supplements? Are you taking vitamins/supplements? Yes No

If yes, please list supplements:

Have you seen a lactation consultant after being discharged? Have you seen a lactation consultant after being discharged? Yes No

If yes, with whom?

Have you taken a breastfeeding class? Have you taken a breastfeeding class? Yes No

If so, where?

Please briefly describe your concerns today:

I agree that these statements are true to my knowledge and that this information will only be used to help Christine better understand your current needs. I agree that these statements are true to my knowledge and that this information will only be used to help Christine better understand your current needs. I Agree