Date of birth
Street Address Line 2
State / Province
Postal / Zip Code
Preferred Date of consult
Preferred time of consult
Family History of:
Do you have any medical conditions?
high blood pressure
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
Date of birth
Last weight recorded
Date and weight please
Has your baby had any weight gain issues?
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:
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
Has baby been assessed for a tongue tie?
If yes, by who and any treatment ?
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