REFERRAL DATE *

MM

DD

YYYY

PARENT/LEGAL GUARDIAN *

First Name

Last Name

BABIES NAME *

First Name

Last Name

DATE OF BIRTH *

MM

DD

YYYY

PLEASE INDICATE HEALTH CARE PROFESSION *

Medical Doctor

Pediatrician

Nurse Practitioner

Midwife

Int. Board Certified Lactation Consultant (IBCLC)

REFERRER'S PHONE NUMBER *

(###)

###

####

REFERRER'S FAX NUMBER

(###)

###

####

YOU HAVE COMPLETED A BREASTFEEDING EXAM *

YES

INFANT SYMPTOM CHECKLIST *

Falls asleep while attempting to nurse

Poor latch - including leaking while feeding

Slides off the nipple while attempting to latch

Colic symptoms

Chewing or gumming the nipple while nursing

Reflux symptoms

Unable to hold a pacifier in their mouth.

Short sleep patterns requiring feeding every 1-3 hours

Poor weight gain

Gagging or choking

Other (please explain below)

None

MOTHER SYMPTOM CHECKLIST *

Bleeding nipples

Cracked blistered nipples

Poor or incomplete breast drainage Infection of your breast or nipples

Mastitis or nipple thrush

Other (please explain below)

None

PAIN WHILE BREASTFEEDING *

0 (none)

1

2

3

4

5

6

7

8

9

10 (most severe)