Mastitis Symptom Intake Form
Please use this form to share mastitis-related symptoms, timing, severity, and any care already tried so the situation can be reviewed.
Patient and Contact Details
Full Name
*
First Name
Last Name
Preferred Contact Method
*
Please Select
Phone
Email
Text
Contact Number or Email Address
*
Age Range
Please Select
Under 18
18–24
25–34
35–44
45–54
55–64
65+
Mastitis Symptom Details
Main symptoms experienced
*
Breast pain
Redness
Swelling
Warmth
Lump/blocked area
Fever
Chills
Body aches
Nipple pain
Discharge
Other
Affected breast/side
*
Left
Right
Both
Symptom onset date and time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Symptom severity
*
Mild
Moderate
Severe
Symptom change
*
Worsening
Improving
Unchanged
Feeding, Pumping, and Care History
Current feeding/pumping status
*
Breastfeeding/Chestfeeding
Pumping
Both breastfeeding/chestfeeding and pumping
Not currently feeding or pumping
Affected side or area
Please Select
Left breast
Right breast
Both breasts
Specific area/other
Care already tried
Rest
Increased fluids
Warm compress
Cold compress
Massage
Continued feeding/pumping
Over-the-counter pain relief
Other
Medications or antibiotics already taken for this issue
Additional Notes and Follow-up
Current temperature or fever present?
*
No
Yes, fever present
Temperature recorded
Best time to reach you
Hour Minutes
AM
PM
AM/PM Option
Additional notes or concerns
Submit
Should be Empty: