BREASTFEEDING PEER COUNSELOR CONTACT LOG Prenatal ...

BREASTFEEDING PEER COUNSELOR CONTACT LOGMother’s name:Mother’s ID Number:Address: City: State: Zip:Phone: _______________ Breastfed ever? Due date: / /Baby’s date of birth: / / Baby’s name:Baby’s birth wt. Discharge wt. Two week wt.Type of contact: 1=phone 2=home visit 3=group class 4=mail 5=clinic visit 6=hospital visit7=otherPrenatal Contacts1 2 3 4 5 6 7DateType of ContactContent (check areas discussed)Breastfeeding barriersBreastfeeding benefitsBasic breastfeeding techniqueBreastfeeding managementReturn to work or schoolClass or group invitationWIC ReferralPostpartum Contacts1 2 3 4 5 6 7DateType of ContactContent (check areas discussed)Baby’s bowel movementsBaby fussy/colickyBaby sickBreastfeeding barriersBasic breastfeeding technique(position/latch)Breast infectionClass or group invitationEngorgement

Type of contact: 1=phone 2=home visit 3=group class 4=mail 5=clinic visit 6=hospital visit 7=otherPostpartum Contacts 1 2 3 4 5 6 7Growth SpurtLet-down reflexMilk Supply IssuesMedical situation/medication useNursing schedulePremature infantPumping/hand expressionRelactationReturn to work or schoolSore nipplesTeethingWeaningWIC referralDateNarrative Documentation of ContactsAge weaned from breast:Reason:_________________________________Breastfeeding Counselor Signature: __________________________ Date:______________WIC-49 7/05