Lactation Consultation Intake Form

The Lactation Consultation Intake Form is specifically designed for International Board Certified Lactation Consultants (IBCLCs), hospital-based lactation programs, private breastfeeding consultation practices, and pediatric offices that provide lactation support services. This breastfeeding consultation form captures the detailed maternal and infant history that lactation professionals need to assess feeding difficulties, develop a care plan, and track progress across follow-up visits. The form is structured to be completed by the breastfeeding parent before the consultation, ensuring the IBCLC has a complete clinical picture before the session begins.

This IBCLC intake form includes comprehensive sections for maternal information (health history, breast surgery history, hormonal conditions, PCOS, thyroid disorders, diabetes, previous breastfeeding experience), birth details (gestational age, birth weight, delivery method, complications, NICU stay, skin-to-skin timing, first feed timing), and infant information (current age and weight, weight gain trajectory, jaundice history, tongue-tie assessment, latch quality). The feeding history section captures current feeding method (exclusively breastfeeding, pumping, supplementing with formula or donor milk), feeding frequency and duration, supplementation details, pump brand and flange size, and milk supply concerns. A current concerns checklist addresses the most common reasons parents seek lactation support: painful latch, low supply, oversupply, engorgement, mastitis, nipple damage, slow weight gain, breast refusal, return-to-work pumping, and weaning guidance.

The medications section screens for drugs that may affect milk supply or safety during breastfeeding (birth control, antidepressants, decongestants, herbal galactagogues), while the insurance field supports practices that bill lactation services through medical insurance, which is increasingly covered as a preventive service under the ACA. The integrated appointment booking field allows parents to schedule their initial consultation or follow-up visit directly through the form. This streamlined intake process helps lactation consultants maximize hands-on assessment time during the visit rather than spending valuable consultation minutes gathering background information.