Formula Fed Baby Client History Form Mother's Full Name First Last Mother's Email Address* Enter Email Confirm Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mother's date of birth Day Month Year Date of birth of baby/ babies Day Month Year Age of baby / babies now Gestation of baby / babies at birth Any pregnancy abnormalities? Yes No Details of pregnancy abnormalitiesName(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 If 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 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 feed within one hour of birth? Yes No Did baby / babies feed a second time within 8 hours of birth? Yes No Has baby / have babies ever breastfed? Yes No If 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? Yes No 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 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.
