Initial Consultation Intake Form 1st April 202024th March 2021 by Ed Parent details Parent's name Date of birth Address Phone number Email address GP name and surgery Baby details Name of baby Date of birth How was your baby born? Vaginal deliveryInduced vaginal deliveryPlanned c sectionEmergency c sectionInstrumental delivery (forceps/ventouse) Place of birth Baby’s gestation Baby’s birthweight Baby’s current weight First baby YesNo Have you breastfed before? For how long? How was your pregnancy? How can I help? antenatal supportweight gain issuespain/discomfortdifficulty latchingblocked ducts/mastitisinduced lactation/relactationsupply issuesrecurrent thrushallergy issuesrefluxother (please specify) Other (if applicable) How are you currently feeding your baby? What would you like to achieve? Medical conditions Please let me know any medical conditions you have Which medications do you routinely take? Do you have any allergies? Anything else you feel I should know? Parking instructions (if applicable) How did you hear about me? Have you read, and are you happy to agree to my Consent and GDPR policies? Δ
