Penny Heywood – Classical Homeopath (R.S. Hom) & Lactation Consultant (IBCLC) serving the community of Brockley and South East London
It will be helpful if you can provide the following information prior to an appointment.
Date of Birth*
MF
Infant Date of Birth*
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:
GENERAL MEDICAL BACKGROUND
Are you a smoker? YesNo
MENTAL HEALTH
Anything else of note:
OBSTETRIC
Labour: VaginalAssistedC sectionMedicationComplicationsSkin to skinBreastfeeding after birth
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). I give my consent to Penny Heywood (IBCLC) Lactation Consultant contacting me by telephone or email in order to provide information and ongoing support. I have read and understood the above and I give my informed consent for the consultation. Today's date*
