Breastfeeding Pre Consult Form

Name

First Name Last Name
Email
example@example.com
Phone Number
Date of birth

- Day - Month Year
Date Date Picker Icon

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parking instructions
Preferred Date of consult

- Day - Month Year
Date Date Picker Icon
Preferred time of consult

: Hour Minutes 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 Date Picker Icon
Birth weight
Last weight recorded
Date and weight please
Has your baby had any weight gain issues?
Gender
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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Child's Details

Labour and Birth

Feeding history