Client Pregnancy Consultation Form
The following information will be used to help plan a safe and effective treatment. Please answer the questions to the best of your knowledge. All information will remain private & confidential.
Treatment Required
Antenatal classes
Antenatal breastfeeding
Dad to be Class
Birthplan design
Breastfeeding support
Other
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Parity (Number of births)
Gravity (number pregnancies)
Pregnancy Week (if applicable)
*
Due Date (or baby date of birth)
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
Phone Number
*
-
Prefix
Phone Number
E-mail
*
Occupation
How did you hear about me?
*
Website / Online Search
Instagram
Facebook
Referral
Other
If Referral, please list name
If Other, please let me know
What is your expectations from this consultation?
*
Pregnancy Information(any complications, delivery type):
Current Medication (incl vitamins):
*
Tell me about your baby (delivery, age, sex, birthweight and last recorded weight, any concerns)
Previous breastfeeding experiences and difficulties (if any)
Your General Health
Stress Levels
*
High
Medium
Low
n/a
Exercise / Hobbies?
If you checked yes to any of these please provide further information. If not mark N/A
*
Any known allergies (eg: aspirin, latex, nuts, essential oils)?
*
Yes
No
Are you a smoker?
*
Yes
No
Social
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
*
Yes
No
Do you drink alcohol
*
Yes
No
What is your daily water intake (glasses / litres)
*
Have you experienced any of these health conditions in the past or present?
*
Hormone Imbalance (eg thyroid, PCOS / irregular cycle)
Depression/Anxiety
Cancer/chemotherapy
Breast surgery
Diabetes
Obesity
Other
None
Please detail any other conditions:
Is there any other information you would like to make your midwife aware of? If yes, please give details:
I occasionally contact clients to follow up on a session and I also send booking confirmation and a reminder via email / SMS. I occasionally send emails regarding company news, updates, special offers etc. You may unsubscribe from these marketing emails at any time. Please confirm you give your permission for Your Midwife to:
*
Contact you about appointment and relevant follow up.
Send occasional emails with news, special offers etc.
Signature
*
Thank you for taking the time to complete this form - I look forward to seeing you soon.
Laura
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