Bridget Ingle

Medical History for Lactation Consultation

The following questions are only for lactation/infant feeding appointments. Please be brief.

Please complete the below medical history information ONLY IF REQUESTED TO DO SO as soon as you have made a booking or at least 24 hours prior to your appointment.

* = mandatory response required

Please correct the following errors before submitting the form again.

Appointment date

Mother's details

Mother's name

Your email address

Your mobile phone number

Your past medical conditions

Your current medical conditions (esp thyroid, diabetes, PCOS, endometriosis, infertility)

Surgery (esp breast or gynae)

Medications and supplements

Total pregnancies (incl current)

Number of live births

Pregnancy and breastfeeding summary of PREVIOUS children (if applicable)

If you are pregnant now, please complete this ANTENATAL SUMMARY:

Due date of this baby

Planned birth date (if known)

Your current pregnancy gestation (in weeks)

Notable pregnancy situations or conditions

Hospital/obstetrician/midwife

Baby's details

Child's name

Child's date of birth

Gestational number of weeks at birth

Child's current age in weeks/months

Pregnancy summary (medical circumstances, etc)

Labour summary (induction, syntocinon, epidural, emergencies, etc)

Birth summary (natural, forceps, vacuum, emerg C/S, elective C/S)

Baby's condition after birth

Mother's condition after birth

Baby medical conditions