The Feeding Space - Client information form

Client information form

Kerry Knight IBCLC L-315498
Mother/parent 1 details

If breastfeeding, please write the lactating parent's details here
Name

First NameLast Name
Date of birth

DayMonthYear
Date
Contact number
Email
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

PostcodeCountry
How did you find The Feeding Space?

Other
Parent 2 details
Name

First NameLast Name
Contact number
Email
example@example.com
Baby's details
Is your baby a singleton, or one of multiple
Baby name

First NameLast Name
Baby's DOB

DayMonthYear
Date
Gestantional age at birth (in weeks and days)
Baby's birth weight
Baby's current weight
Baby 2 name (if multiple)

First NameLast Name
Baby 2 birth weight
Baby 2 current weight
Baby 3 name (if multiple)

First NameLast Name
Baby 3 birth weight
Baby 3 current weight
Are you tandem feeding with an older sibling?
If tandem feeding, older child's name

First NameLast Name
Tandem feeder's DOB

DayMonthYear
Date
Health professionals
GP name and address
Health visitor name and contact details (if known)
Mother/Parent 1's medical history
Have you had any previous surgeries on the breasts, heart, lungs or chest? If YES, please provide details.
Allergies
Current medications
Do you have any other medical conditions (physical or mental health) that you would like me to be aware of?
How was your pregnancy? Please describe any complications you may have experienced.
What type of delivery did you have? Please provide details around labour, interventions (e.g. forceps/emergency c-section) and medications administered (induction, pain relief, epidural etc.)
Baby's medical and feeding history
Did your baby spend any time in the NICU / SCBU? Please provide details.
Current medical conditions, medications and allergies (if any).
Have any health professionals expressed concerns about your baby's weight gain?
What sort of support and information have you already received for your infant feeding worries?
Is your baby subject to a feeding plan? If yes please describe it here. (This is usually a certain volume of milk to be fed daily, recommended by a health care professional.)
Please describe your feeding journey to date, including details of breastfeeding, supplementation (if any) with either expressed breastmilk/formula and additional breastfeeding tools you may use (e.g. nipple shields/dummy).
How can The Feeding Space help
Please tell me why you are here (select all that apply)

Other
Please describe your concerns and give more details around why you have come to The Feeding Space.
Please use this space to share anything additional you would like me to know that may not have been covered above.
I am aware that the Client Information form, Signed Terms & Conditions and payment must be completed in order for the consultation to proceed. If no payment has been received within 24 hours of booking a consultation then The Feeding Space reserves the right to release the appointment to another client.
Should be Empty:

Client information form

Mother/parent 1 details

Parent 2 details

Baby's details

Health professionals

Mother/Parent 1's medical history

Baby's medical and feeding history

How can The Feeding Space help