Virtual Lactation Consultation To book an appointment, please fill out the booking form and I will get back to you within 24 hours. General Information Full Name: Date of Birth: Baby's Name: Email: Phone: Background Information Please give me a brief description of your issue or any background information that you feel will help with my assessment. Do any family members on either side have? Food allergiesAsthmaEczemaGenetic Disorders Do you have any medical conditions? AsthmaAnemiaAnxiety DisorderCancerConstipationDepressionDiabetesEating DisorderGi DisorderHeart DiseaseHemorrhoidsHigh Blood PressureInfertilityLiver DiseaseNipple ProblemsPcosThyroid DisordersYeast InfectionsOther Medical Conditions. If you answered yes to any of the above questions can you please elaborate? Have you had any surgeries to your breasts? YesNo Have you ever had your thyroid tested? YesNo Did you experience breast growth and/or changes during your pregnancy? YesNo Did you feel your milk “come in” after your baby was born? (This usually happens around day 2-3 post-partum) YesNo Are you taking any medications or supplements? YesNo Did you have difficulty conceiving baby? YesNo Do you have any other children? YesNo If yes, did you breastfeed them and for how long? I accept the terms and conditions (Signature)Please complete the form and email it back to myself prior to our appointment.