Intake History Form

Intake History Form
Name*

First NameLast Name
Have you breast/chestfed before? If so, for how long?
Mother/Parent date of birth*
Contact phone number*
How can I help?*

Antenatal supportWeight gain issuesPain/discomfortDifficulty latchingSupply issuesTwins/MultiplesRelactation/induced lactationRefluxOther (please specify below)
Other (if applicable)
How are you currently feeding your baby?
What would you like to achieve?
Any history of the following:*

ThyroidOvarian CystPCOSType 1 DiabetesType 2 DiabetesOther
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?*

NoneReductionMastopexy (lift)AugmentationInjuryOther
Have you ever experienced miscarriages?
Number of other pregnancies
Did you experience breast changes/growth in pregnancy?*
Should be Empty: