Email

Who referred you to Jan Tedder?

Address and Phone Number

Baby's: full name, DUE date, and Date of Birth.

Mother's Prenatal History

Did you have any significant past medical problems (such as diabetes, hypertension, depression)? Any history of breast surgery? Any prenatal medications?

Pregnancy History

List any medical problems during your pregnancy. Did you have expected changes in your breast during pregnancy?

Labor and Delivery History

Did you have any unexpected interventions during L&D (induction, epidural, C-Section, excessive blood loss, hypertension)?

Help and support at home.

Did baby have any complications (time away from mother, time in NICU)?

Baby's Weights

What was baby's birth weight? List other weights and how old baby was at that time.

What was your initial breastfeeding experience? Did you breastfeed the first hour? What help was needed?

What are your concerns today?

When did it start? What have you tried? Who helped you?

What are your breastfeeding goals?

Insurance Coverage

If you have not done so already, click the insurance button on our website page if you have BCBS, Cigna or a PNOA plan (Including Etna and United).

Consent Form

I consent to having Jan Tedder, BSN, FNP, IBCLC collect this information to provide me with professional lactation help.

Lactation Consultation Form