Breastfeeding Assesment

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

Details

Date of Birth*

MF

Infant Date of Birth*


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).

Today's date*