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*