Mother Infant Assessment
Infants – Less than one year old
Patient’s Name
Birthday
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Today’s Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Gender
Male
Female
Please use this form if your child is Infant
Medical Problems
Heart disease
Bleeding disorders
Other
Birth Weight
Present Weight
Birth Hospital
Vaginal birth
C-Section Birth
Any birth complications?
Are you presently breastfeeding?
Yes
No
If no, how long since you stopped breastfeeding?
Medical History:
Infants are usually given vitamin K at birth. Did your child receive the vitamin K shot?
Yes
No
Was your infant premature?
Yes
No
If yes, how many weeks?
Does your infant have any heart disease?
Yes
No
Has your infant had any surgery?
Yes
No
Has your infant experienced any of the following? Please check or elaborate as needed.
Shallow latch at breast or bottle
Gumming or chewing your nipple when nursing
Falls asleep while eating
Pacifier falls out easily
Slides or pops on and off the nipple
Milk dribbles out of mouth when nursing/bottle
Colic symptoms / Cries a lot
Short sleeping requiring feedings every1-2hrs
Reflux symptoms
Snoring, noisy breathing or mouthbreathing
Clicking or smacking noises when eating
Feels like a full-time job just to feed baby
Spits up often. Amount/ Frequency
Nose congested often
Gagging, choking, coughing when eating
Baby is frustrated at the breast or bottle
Gassy (toots a lot) / Fussy often
Lip curls under when nursing/with bottle
Poor weight gain
Hiccups often
Spits up often. Amount/ Frequency
How long does baby take to eat?
How often does baby eat?
Is your infant taking any medications?
Reflux
Thrush
Name of medication
Has your infant had a prior surgery to correct the tongue or lip tie?
Yes
No
If yes, when, where, and by whom?
Do you have any of the following signs or symptoms? Please check and elaborate as needed
Creased, flattened or blanched nipples
Poor or incomplete breast drainage
Lipstick shaped nipples
Infected nipples or breasts
Blistered or cut nipples
Plugged ducts / engorgement / mastitis
Bleeding nipples
Nipple thrush
Pain when first latching
Using a nipple shield
Pain during nursing
Baby prefers one side over other
Pain on a scale of 1-10 when first latching
Pain (1-10) during nursing
Right / Left?
Pediatrician
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Lactation Consultant
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Who referred you to us?
Submit
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