Name
First Name
Last Name
Email
example@example.com
Phone Number
Date of birth
-
Day
-
Month
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parking instructions
Preferred Date of consult
-
Day
-
Month
Year
Date
Preferred time of consult
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Partner's name
Family History of:
Food allergies
asthma
breast cancer
diabetes
eczema
genetic disorders
tongue tie
thyroid issues
Do you have any medical conditions?
Asthma
Anxiety disorder
low iron
depression
diabetes
infection
eating disorder
haemorrhoids
high blood pressure
infertility
thyroid diorders
PCOS
STI's
yeast infection/thrush
Have you ever had any injuries or surgeries to your breasts?
Have you ever had your thyroid tested? Or suffer from thyroid problems ?
Did you experience growth or changes to your breasts during pregnancy ?
When did you milk "come in"?
Are you taking any medications or supplements?
Any allergies to drugs or food ?
Did/do you have irregular periods ?
Did you have difficulty conceiving?
How many pregnancies have you had?
Do you have any other children
Please list names, DOB and if they were breastfed
Child's Details
Name
First Name
Last Name
Date of birth
-
Day
-
Month
Year
Date
Birth weight
Last weight recorded
Date and weight please
Has your baby had any weight gain issues?
Gender
Male
Female
Gestational age at birth
Has or is your baby on any medication?
Does your baby have any medical conditions or concerns?
If applicable- Twin details :
Gender, birth and current weight, Issues, medication etc
Labour and Birth
Medication during labour ?
Type of birth?
Briefly describe your labour and birth
Skin to skin post birth?
How was the first feed?
Any issues after the birth?
Reason for requesting lactation consultation:
Feeding history
Concerns or issues
Feeding issues, attachment, suspected tongue tie, thrush, mastitis etc
Breastfeeds per 24 hours
how many feeds is bay having at the breast in 24 hou
Have or are you pumping?
if so, what pump? and how often
Any supplementation? Frequency ? Type ?
Forumla, EBM, bottles, SNS, finger feeds etc
Does baby feed from both sides?
Every feed? some feeds?
Let down signs?
Average time spent on a feed?
Hours between feeds? Is baby demand fed or on a routine?
Does baby feed during the night?
On solids? When and how much?
Use a dummy?
How many wet and dirty nappies in 24 hours
Appearance
Has baby been assessed for a tongue tie?
If yes, by who and any treatment ?
Thank you
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