Breastfeeding Assesment

It will be helpful if you can provide the following information as possible prior to an appointment.

Details

MF


Reason for Consultation

Please give details about why you would like a consultation:

Please note any advice to date from your healthcare provider or other breastfeeding support services you may have accessed:


Medical History - Maternal

GENERAL MEDICAL BACKGROUND

Are you a smoker? YesNo

MENTAL HEALTH

Anything else of note:

OBSTETRIC

Labour:
VaginalAssistedC sectionMedicationComplicationsSkin to skinBreastfeeding after birth


Medical History - Infant

Health Issues:
JaundiceInfectionNICUWeightTongue tieRefluxThrushOral abnormalitiesOther

INFANT FEEDING HISTORY
Please give a brief summary of feeding so far including use of bottles, formula, expressing, nipple shield use, and dummies

CONSENT

I give my consent for Penny Heywood (IBCLC) Lactation Consultant to work with me. This includes: observing a complete breastfeed and manual examination of breast and/or examination of baby if necessary. I give my consent to Penny Heywood (IBCLC) Lactation Consultant to share appropriate information with my Healthcare Professionals (Midwife, Health Visitor or GP).

Date: