What is the lactation consultation intake form template?
Parents who book a lactation consultant are often tired, sore and short of time. Asking them to recall birth weight, feeds per day and their own health history at the start of a visit takes away from the part that helps: watching a feed and working through it together.
This intake gathers that background before you meet. The first page covers the parent's contact details, baby's name and date of birth, weeks of pregnancy at birth, birth and recent weights, the type of birth and any time apart afterwards. The parent then says how baby is fed at the moment, how many feeds and wet diapers there are in 24 hours, and ticks what they'd like help with, from latch and nipple pain to supply worries, returning to work or weaning.
Parents who pick pumping with expressed milk given by bottle are asked which pump they use, how often and how much, and whether their flange size has been checked. Anyone who ticks a hot, red, painful area with fever sees a note to contact their doctor or midwife that day. The second page covers the parent's health, previous feeding experience, goals and where the consultation should happen. Each intake is filed as a PDF in your FileIt vault.
- Best for
- Private lactation consultants, IBCLCs, breastfeeding clinics and postnatal services
- Filled in by
- The parent who is feeding the baby
- Time to complete
- About 8 minutes, on a phone
- Includes
- Birth and weight details, feeding method with pump follow-ups, a concerns checklist, an urgent-symptom note, health history, goals, visit choice, consent and signature
Who uses a lactation consultation intake form?
- Home-visit lactation consultants booking a first consultation
- Clinics triaging requests so urgent latch or weight problems are seen first
- Exclusive pumpers wanting help with output or pump fit
- Parents of babies who spent time in special care
- Planning a return to work while continuing to feed
- Virtual consultations where the consultant can't see the paperwork in person
Questions on this lactation consultation intake form
31 questions over 2 pages · includes signature, conditional questions, multiple pages, consent checkbox.
1 You, baby & feeding
- Your full name*
- Mobile phone*
- Email*
- Baby's first name*
- Baby's date of birth*
- Weeks of pregnancy at birth
- Birth weight
- Most recent weight and date
- Type of birth Vaginal birth · Assisted (forceps or vacuum) · Planned cesarean · Unplanned cesarean
- Did baby spend time in special care or away from you after birth?
- How long, and why? asked only when it applies
- How is baby fed at the moment?* Breast or chest feeding only · Breast or chest feeding plus formula · Pumping, with expressed milk given by bottle · Formula only, hoping to bring milk back
- Which pump do you use?* asked only when it applies Hospital-grade rental pump · Double electric pump · Single electric pump · Wearable in-bra pump · Manual (hand) pump
- How often do you pump, and roughly how much each time? asked only when it applies
- Has anyone checked your flange (breast shield) size? asked only when it applies
- Feeds in 24 hours
- Wet diapers in 24 hours
- What would you like help with?* Latch or positioning · Nipple pain or damage · Worried about low supply · Oversupply or fast flow · Baby sleepy or fussy at the breast · Baby's weight gain · Engorgement or blocked ducts · A hot, red, painful area with fever or flu-like feelings · Combining breast and bottle · Returning to work · Weaning
- Tell us more in your own words
2 Your health & goals
- Your health — any of these?* Previous breast or chest surgery · PCOS · Thyroid condition · Diabetes, including in pregnancy · High blood pressure · Anemia or heavy blood loss at birth · Low mood or anxiety since the birth · None of these
- Medicines or supplements you take now
- Have you fed a baby before? This is my first baby · Yes, and it went well · Yes, and it was difficult
- What made it difficult? asked only when it applies
- Anything about baby's health we should know?
- What would a good outcome look like for you?*
- Who supports you at home?
- Where would you like the consultation?* At my home · At the clinic · Video call
- Home address* asked only when it applies
- Days and times that suit you
- Consent*
- Signature*
The lactation consultation intake form, page by page
1 You, baby & feeding
Contact details, baby's first name and date of birth are required. Weeks of pregnancy at birth, birth weight, the most recent weight and date, and the type of birth are optional, as is whether baby spent time in special care or away from you after birth (a yes asks how long and why).
How is baby fed at the moment? is required and offers four answers. Pumping reveals Which pump do you use?, the pumping routine and a question about flange size. Feeds and wet diapers in 24 hours are simple counts. What would you like help with? needs at least one tick; choosing the fever option shows a note to call a doctor, midwife or health visitor today. A free-text box lets the parent explain in their own words.
2 Your health & goals
Your health — any of these? is a required checklist including previous breast or chest surgery, PCOS, thyroid conditions, diabetes, high blood pressure, anemia and low mood or anxiety since the birth. The parent lists medicines or supplements and says whether they've fed a baby before; if it was difficult, they can say why. They can add anything about baby's health, then answer the required What would a good outcome look like for you? They choose a home, clinic or video consultation (home asks for the address), give suitable times, read what to have ready, agree to the consent statement and sign.
Make the template yours
- Add your fees, cancellation policy and service area to the cover text
- Change the visit options if you only offer clinic or video appointments
- Add a file question for a photo of a latch or a weight chart
- Adjust the concerns list to match the problems you see most
- Edit the urgent-symptom note to reflect your own referral advice
- Replace the consent wording with the version your practice uses
Tips for a better lactation consultation intake form
- Look at the concerns and the urgent-symptom answer as soon as each intake arrives
- Use the parent's own goal to frame the plan you agree at the end of the visit
- Ask parents to keep a rough feed log for a day before you meet
- Store intakes in a vault folder that only you or your clinical team can open
- Keep the form short to fill on a phone; parents often answer one-handed
- This is a starting template; adapt it to your practice and local health-privacy rules
Every response becomes a PDF in your vault
Each intake is saved as a PDF in the vault folder you choose, and you're emailed so you can confirm a time. The parent can receive a copy of their answers.
In Responses you can filter by feeding method or visit type, open each PDF before you go, and export to CSV for your own records.
- Start from this template. It opens in the FileIt Forms designer — change any question, add pages, set the rules for when questions appear.
- Share it. Turn on a public link, or send it to people by email, each with their own link. They don’t need a FileIt account.
- Get the answers as PDFs. Each response is saved as a PDF in the vault folder you choose, with uploaded files attached — and listed in a Responses table you can export to CSV.
Lactation consultation intake form: frequently asked questions
Is this lactation intake template free?
Yes. It's one of the starter templates in FileIt's Forms app, which comes with every account, including the free plan.
Do parents need a FileIt account to fill it in?
No. They open your link or an emailed request, answer the questions and sign on screen.
Does the form alert me to urgent symptoms?
It shows the parent a note to seek same-day medical advice if they tick the fever option. It doesn't send you a separate alert, so check new intakes promptly.
Are the pumping questions shown to everyone?
No. Pump type, routine and flange size appear only when the parent says they're pumping and giving expressed milk by bottle.
Can I use it for chestfeeding parents?
Yes. The wording refers to breast or chest feeding throughout, and every label can be edited in the designer.
Is the consent statement ready to use?
It's a starting point. Adapt it to your practice, your certification body and your local privacy rules.