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)
Gestational age of baby at birth:*
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 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 DeliveryForcepsVacuum-assistedEmergency C-sectionPlanned 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 noticeableSlightModerateHeavy
Anything else you would like to share about your experience:
Should be Empty:

Labour and Delivery