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Dalaney Young, BS MCH, IBCLC
dalaney@newdaylactation.com
720-234-3643
Mother and Infant(s) Information
Mother's Full Name
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Mother's DOB
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Mother's E-mail Address
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Home Address
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City
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Zip Code
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Mother's Phone Number
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Secondary Phone Number (if available)
Is there a special parking situation at your residence that I need to be aware of when I visit?
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OBGYN or Midwife Name
*
OBGYN or Midwife City
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Hospital or Birthing Center
*
Please check any breastfeeding issues you are experiencing.
Low Supply
.
Oversupply
.
Cracked Nipples
.
Sore Nipples
.
Engorgement
.
Breast pain
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Weight Gain Issues
.
Breast Pump Questions
.
Desire to Wean From Bottle
.
Sleepy Infant
.
Please list in your own words the reason for the home visit and concerns you may have.
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Infant #1 Full Name
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Infant #2 Full Name (if applicable)
Infant #3 Full Name (if applicable)
Infant #1 DOB
*
Infant #1 Birth Weight
*
Infant #1 Discharge Weight
*
Information on Infant #2 and/or Infant #3 if applicable
.
Infant #2 DOB
Infant #2 Birth Weight
Infant #2 Discharge Weight
Infant #3 DOB
Infant #3 Birth Weight
Infant #3 Discharge Weight
Infant's Pediatrician
*
Pediatrician's Practice Name
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Pediatrician's City
*
Mother's Health History
Previous pregnancies
*
Yes
No
Previous Births
*
0
1
2
3
4 or more
Did you breastfeed your other children?
Please check any that apply to the mother.
Infertility
.
PCOS
.
Reynaud's Syndrome
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Gestational Diabetes
.
Type 1/2 Diabetes
.
Breast implants
.
Breast reduction
.
Chest Surgery
.
Nipple Piercing (past or present)
.
Drug Dependence
.
Alcohol Dependence
.
HIV Positive
.
Tobacco use
.
Depression, Anxiety, Panic Attacks, Baby Blues. Please list medications that you were on during pregnancy and/or after birth or if you think you might need to be on medications. Please list concerns you have with breastfeeding and medications. I will work with you in finding the safest medication for both of you to ensure breastfeeding if possible. Mental health is just as important as our physical health when it comes to taking care of our little ones.
Allergies (please list)
Are you allergic to any medications?
Please list any medications, herbals or supplements you are taking.
Are there any other health issues that may be a concern?
Current Child Delivery and Birth Information
Gestational Age of Infant
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Type of Birth
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Vaginal
C-Section
Was your baby in the NICU or Special Care Nursery?
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Yes
No
Epidural
.
Vacuum
.
Forceps
.
Induction
.
Pitocin
.
IV use
.
Blood transfusion
.
VBAC
.
Please discuss any other items of concern about your birthing experience? Are you feeling loss if the experience was not what you expected (i.e. emergency c-section, etc.)
Please check any that apply in regard to the infant(s) either current or after birth.
Jaundice
.
Low Blood Sugar
.
Temperature Regulation Issues
.
Respiratory Issues
.
Please discuss any other infant health issues.
How did you find New Day Lactation?
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Payment Information
Please Note: Credit card information will not be charged prior to completion of appointment. However, a $2
5.00 fee
will be charged to your credit card if you cancel within 12 hours of your appointment time.
Name on Card
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Credit Card Type
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Visa
MasterCard
American Express
Discover
Credit Card Number
*
Expiration Date (mm/yy)
*
CID Number (3 digit code on the back of the card):
*
Who is your insurance carrier?
*
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