Breastfeeding Baby Client History Form

Mother's Full Name

First Last

Mother's Email Address

Enter Email Confirm Email

Please supply your address and postcode*

Street Address City ZIP / Postal Code

Mother's Date of Birth

Date of birth of baby/babies

Age of baby/babies now

Gestation of baby / babies at birth

Any pregnancy abnormalities

Name(s) of baby / babies

Method of delivery

Please supply the name and address - including postcode - of your family GP

Do you smoke?

Yes
No

Have you ever smoked?

Yes
No

When 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?

Yes
No

What medication are you taking?

Baby's / babies' birth weight

Subsequent weights and dates where appropriate

Did mother and baby / babies have skin to skin contact within one hour of birth

Yes
No

Did mother and baby / babies have uninterrupted skin to skin for at least one hour within the first 2 hours of birth?

Yes
No

Did baby / babies breastfeed within one hour of birth?

Yes
No

Did baby / babies breastfeed a second time within 8 hours 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 describe baby's / babies' nappies - urine and stools - frequency per day or week, and colour / texture of stools - and how this has changed, where relevant

Please say if mother's breasts are painful during, or after feeding

Please comment on baby's / babies' behaviour during and after feeds

Please comment on any change to breast or nipple after baby has finished a feed

Please comment on how often baby / babies feed in 24 hours

Are 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 appropriate

Please detail any engorgement or other breast issues

Previous 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

Phone

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