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 County / State / Region ZIP / Postal Code Country

Mother's date of birth

DD

MM

YYYY

Date of birth of baby/ babies

DD

MM

YYYY

Age of baby / babies now

Gestation of baby / babies at birth

Any pregnancy abnormalities?

Yes
No

Details of 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

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 mother and baby / babies have skin to skin contact within one hour 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 stools

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

Please say what type of dummies, bottles and bottle teats baby is using

Please say what infant milk baby is having

Please comment on baby's / babies' sleeping patterns

Previous 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

Name

This field is for validation purposes and should be left unchanged.