Breastfed Baby Access Advocacy Form Mother's Full Name First Last Mother's Email Address Enter Email Confirm Email Mother's full address including postcode Date of birth of baby/babies Day Month Year Age of baby/babies now Gestation of baby / babies at birth Any pregnancy abnormalitiesName(s) of baby / babiesPlease supply the name and address - including postcode - of your family GP Do you smoke?* Yes No Does the other parent smoke?* Yes No 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?Does the other parent or their close family members have any medical conditions which may affect the infant's breastfeeding? For example hormonal or thyroid, IBS, immune disorder, allergies etc. Please disclose all maternal conditions.Are you taking any drugs or medications, including hormonal contraceptive? Yes No What medication are you taking?Baby's / babies' birth weight Subsequent weights and dates where appropriateDid mother and baby / babies have skin to skin contact within one hour of birth Yes No Did baby / babies breastfeed within one hour of birth? Yes No Has baby / have babies ever had formula? Yes No If so from what age and what caused the first supplement?Please comment on success or otherwise in expressing milk for babyPlease comment on how often baby / babies feed in 24 hoursAre you now using, or have you previously used, dummies, nipple shields, supplementary nursing system, or bottle teats? Please comment on baby's / babies' sleeping patterns now and previously where appropriatePlease detail any other breast feeding issuesAny 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 support and information which I may receive. I hereby agree to reimburse Shel Banks IBCLC Lactation Consultant at the rate mutually agreed. 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 NameThis field is for validation purposes and should be left unchanged.
