Breastfeeding Baby Client History 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 DD MM YYYY Date of birth of baby/babies DD MM YYYY Age of baby/babies nowGestation of baby / babies at birthAny 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?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?Baby's / babies' birth weightSubsequent weights and dates where appropriateDid mother and baby / babies have skin to skin contact within one hour of birthYesNoDid mother and baby / babies have uninterrupted skin to skin for at least one hour within the first 2 hours of birth?YesNoDid baby / babies breastfeed within one hour of birth?YesNoDid baby / babies breastfeed a second time within 8 hours of birthYesNoHas baby / have babies ever had formula?YesNoIf 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 relevantPlease say if mother's breasts are painful during, or after feedingPlease comment on baby's / babies' behaviour during and after feedsPlease comment on any change to breast or nipple after baby has finished a feedPlease 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 engorgement or other breast issuesPrevious 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 NameThis field is for validation purposes and should be left unchanged.
