The Feeding Space - Client information form

Client informtation 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
Parent 2 details
Name

First NameLast Name
Contact number
Email
example@example.com
Baby's details
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
If tandem feeding, older child 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, if any.
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?*

YesNo
What sort of support and information have you already received for your infant feeding worries?
Is you 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)*

Breastfeeding is painfulI have damaged nipplesI am concerned I do not have enough milkI am concerned I have too much milkI have flat/inverted nipplesI have/had mastitisI am expressingI feel my baby has a shallow latchMy baby does not attach to the breastMy baby is fussy at the breastMy baby is unsettled between feedsMy baby makes a clicking sound when feedingMy baby is not gaining weight as expectMy baby keeps slipping off during feedsMy baby makes gagging/coughing/spluttering noises during feedsMy baby may be showing signs of refluxI have been advised my baby may have a Tongue Tie - Please note I am unable to diagnose Tongue Ties but am able to perform oral assessments and can report my findings.I would like my baby to take a bottle but they won'tOther
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.
Should be Empty:

Client informtation 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