Intake History Form
Name
*
First Name
Last Name
Have you breast/chestfed before? If so, for how long?
Mother/Parent date of birth
*
Contact phone number
*
How can I help?
*
Antenatal support
Weight gain issues
Pain/discomfort
Difficulty latching
Supply issues
Twins/Multiples
Relactation/induced lactation
Reflux
Other (please specify below)
Other (if applicable)
Gestational age of baby at birth:
*
How are you currently feeding your baby?
*
What would you like to achieve?
Any history of the following:
*
Thyroid
Ovarian Cyst
PMOS (PCOS)
Type 1 Diabetes
Type 2 Diabetes
Other
Any other medical/mental health history:
*
Are you currently taking any medications? (Please include any contraceptives/herbs)
*
Do you have any allergies? (If so, please specify):
*
Have you had any breast/chest surgery?
*
None
Reduction
Mastopexy (lift)
Augmentation
Injury
Other
Have you ever experienced any fertility issues or fertility treatment? If so, please give details below:
*
Number of other pregnancies
*
Did you experience breast changes/growth in pregnancy?
*
Labour and Delivery
Delivery:
*
Vaginal Delivery
Forceps
Vacuum-assisted
Emergency C-section
Planned C-section
Any medications during labour:
*
Haemorrhage (bleeding) - defined as more than 500ml for vaginal delivery, or more than 1l for cesarean section?
*
Labour experience:
Postnatal
When did your milk 'come in', if it has?
*
When your milk 'came in' was it
*
Not noticeable
Slight
Moderate
Heavy
Anything else you would like to share about your experience:
Submit
Should be Empty: