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Infant Intake Form

Please fill this form out prior to your first appointment.

All information is submitted through a secure, encrypted connection.

Birthday

Gestation History

Did any of the following occur during pregnancy?

Labor / Delivery History

Were you induced?
Yes
No
What was the baby's presentation at birth?
Normal
Breech
What type of delivery did your child have?
Vaginal
C-Section
Were forceps or suction used to assist in your child's delivery?
Yes
No
Did your child breathe on their own after being delivered?
Yes
No
Were there any concerns with the umbilical cord during birth?
Yes
No
If YES, choose:

Postnatal History

Was your baby in intensive care?
Yes
No
Is your baby breast fed?
Yes
No
Does your baby struggle with feeding?
Yes
No
Does your baby spit up frequently?
Yes
No
Does your baby have colic?
Yes
No

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