La Leche League of North Carolina

Protected: Medical Questionnaire

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NOTE: If the mother has been told to wean immediately, this is considered an emergency by LLL. If you cannot address the matter right away, pass it on to another Leader who can. Such an emergency may require PLD and Advisory Council assistance - contact your PL Leader ASAP by phone or email at apl@lllofnc.org for assistance.

---- DEFINING THE PROBLEM / SUGGESTION ----

Symptoms, treatments already tried, etc.

What are her sources of breastfeeding information? What has mother been told? By whom? What does SHE think is going on?

---- HEALTH CARE PROVIDER'S (HCP) INPUT ----
---- LEADER'S INPUT ----

Please include the following details. Specific BAMS, WAB, Hale's Medications and Mother's Milk pages shared? Read to her and/or hard copy provided? Website links shared.

---- FAMILY SUPPORT SITUATION ----

If yes, include ages

If yes, when?

---- INFANT/CHILD ----
---- BREASTFEEDING ----

sleepy, content, fussy, colicky, sick, or specify other

Specify the other intake (formula, donor milk, juice, cereal, other)? When started? Why?

 

Confirm spelling and dosage, include prescription, OTC, herbals, vitamins.

---- MOTHER ----

Left  breast, right breast, both, nipple pain, breast pain, engorgement

Confirm spelling and dosage, include prescription, OTC, herbals, vitamins.