Intake History
Full Name
*
First Name
Last Name
Mother/Parent Date of Birth
*
-
Day
-
Month
Year
Date
Phone Number
*
-
Area code
Number
Preferred pronoun
She/her
He/Him
They/Them
Problem:
*
Nipple Pain
Latch
Breast Refusal
Undersupply
Oversupply
Slow weight gain
Multiples
Relactation
Bottle feeding
Other
Please describe what help/support you would like:
Others Consulted:
Lactation Consultant
Breastfeeding Counsellor
Doctor
Midwife
Health Visitor
Doula
Friend
Family
Other
Health History
Any history of?
Thyroid
Ovarian Cyst
PCOS
Type I Diabetes
Type II Diabetes
Any other medical or mental health history:
Current Medication (inc herbs/vitamins/contraceptives)
Any Allergies?
*
Yes
No
If yes please state what you are allergic to:
Breast or Chest Surgery?
None
Reduction
Mastopexy
Augmentation
Biopsy
Injury
Other
Have you had any fertility issues? If yes please can you give further details below.
Yes
No
IVF
IUI
Have you experienced any miscarriages?
Yes
No
Number of other pregnancies
Did you have breast changes in pregnancy?
Yes - slight
Yes - more than two cup sizes
None
Please give any other relevant information regarding fertility and previous preganancies.
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Breastfeeding History
Number of Other Children Breastfed
Child #1 Length of Time?
Child #2 Length of Time
Child #3 Length of Time
Child #4 Length of Time
Child #5 Length of Time
How did Breastfeeding go with the older child(ren)?
Easy
Difficult
Please Describe:
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LABOUR AND DELIVERY
Start of Labour
Spontaneous
Induction (AROM - waters broken)
Induction (Syntocinin - drip)
Induction (Pessary)
Other
Location
Home
Midwife Unit
Hospital
Other
Delivery
Normal vaginal delivery
Forceps
Vacuum-assisted
Emergency C-section
Planned C-section
Medications During Labour
Antibiotics
Yes
No
Haemorrhage (bleeding):
No
Yes (greater than 500mls)
Labour Experience:
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POSTNATAL
How long after birth was baby's first breast feed?
When did your milk 'come in'?
Day
When your milk 'came in' was it?
Not noticeable
Slight
Moderate
Heavy
In the first 24 hours how many times did baby feed?
How often did baby feed in the 2nd 24 hours?
How often did baby feed in the 3rd 24 hours?
Were you separated from baby at all?
None
SCBU/NICU
Other
Any complications with baby?
None
Hypoglycaemia (low blood sugar)
Jaundice
Other
Did baby require any treatment post birth?
Anything else that you wish to share about baby's in-patient experience?
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Current feeding
Is baby receiving?
Exclusively breastmilk at the breast
Exclusively pumped breast milk
Exclusively formula
Combination of breastmilk and formula
Donor milk
Other
How often does baby feed now?
How long is an average feed?
Who ends the feed?
Generally how long is there between feeds?
How long is baby's longest sleep period?
Supplements
Expressed Breast Milk
Formula
None
If baby having supplements, how much is baby having (how many ounces over 24 hours)?
How many wet nappies in a 24 hour period is baby having?
*
How many dirty nappies in a 24 hour period is baby having?
*
What colour are baby's dirty nappies?
*
Is baby having a dummy at all?
Is baby generally?
Calm/alert
Fussy
Sleepy
Other
Is baby taking any medications?
*
What weights have been recorded on your baby (in kg)?
*
Rows
Date
Age
Weight
Birth
5 days
Other
Other
Other
Other
Other
Other
Other
Submit
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