Antenatal Client History Mother's Full Name First Last Mother's Email Address Enter Email Confirm Email Mother's Date of Birth DD MM YYYY Estimated due date of baby/babies DD MM YYYY DOB of any previous babiesGestation of previous baby / babies at birthAny pregnancy abnormalities THIS PREGNANCYCurrently planned method of deliveryPlease supply the name and address - including postcode - of your family GPDo you smoke?YesNoHave you ever smoked?YesNoWhen did you stop smoking?Do you have any medical conditions which may affect breastfeeding? For example hormonal or thyroid, IBS, allergies etc. Please disclose all maternal conditions.Does the baby / do the babies have any medical condition which may affect breastfeeding?Are you taking any drugs or medications, including hormonal contraceptive?YesNoWhat medication are you taking?If you already have an idea of a birth plan, please share relevant elements of it herePlease comment on any main concerns you have about feeding at this stagePrevious breastfeeding maternal history - does this baby have older siblings? How did breastfeeding go?Any other comments?DECLARATION:*The above information is true to the best of my knowledge. I understand that any information, support or expertise offered is done so on the basis of information I disclose above or in person, and so in limiting the information I am limiting the usefulness of any advice which I may receive. I hereby agree to reimburse Shel Banks IBCLC Lactation Consultant at the rate mutually agreed, either before or during the consultation. I agree to Shel Banks sharing the outcome of our discussion with my child's healthcare providers where this is relevant, either via the Child Health Record (Red Book) or by contacting the healthcare professional direct. I agree to Shel consulting with colleagues on my child's feeding history, using anonymous information, so she can provide better care for us. I understand that all personal or identifiable information shared here is confidential except where there is a safeguarding risk to a child or a vulnerable adult, or as specified above. I agree PhoneThis field is for validation purposes and should be left unchanged.
