Formula Fed Baby Client History Form Mother's Full Name First Last Mother's Email Address* Enter Email Confirm Email Mother's date of birth DD MM YYYY Date of birth of baby/ babies DD MM YYYY Age of baby / babies nowGestation of baby / babies at birthAny pregnancy abnormalities?YesNoDetails of pregnancy abnormalitiesName(s) of baby / babiesMethod of deliveryPlease supply the name and address - including postcode - of your family GPDo you smoke?YesNoHave you ever smoked?YesNoIf so, when did you stop?Do you have any medical conditions which may affect feeding?Does the baby / do the babies have any medical condition which may affect feeding?Baby's / babies' birth weightSubsequent weights and dates where appropriateDid mother and baby / babies have skin to skin contact within one hour of birth?YesNoDid mother and baby / babies have uninterrupted skin to skin for at least one hour within the first 2 hours of birth?YesNoDid mother and baby / babies have skin to skin contact within one hour of birth?YesNoDid baby / babies feed within one hour of birth?YesNoDid baby / babies feed a second time within 8 hours of birth?YesNoHas baby / have babies ever breastfed?YesNoIf so for how long, and what caused the first supplement?Please describe baby's / babies' nappies - urine and stools - frequency per day or week, and colour / texture of stoolsPlease comment on baby's / babies' behaviour during and after feedsPlease comment on baby's / babies' behaviour during and after feedsPlease say what type of dummies, bottles and bottle teats baby is usingPlease say what infant milk baby is havingPlease comment on baby's / babies' sleeping patternsPrevious feeding history - does this baby have older siblings? How did feeding go?Does either parent or any close relations have any food allergies?YesNoAny 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 understand that all information shared is confidential except where there is a safeguarding risk to a child or a vulnerable adult. I agree PhoneThis field is for validation purposes and should be left unchanged.
