Lactation Consultation

To book an appointment (“My Baby Bubble Spa”, Shop 5/110 Old Pacific Highway, Oxenford, QLD 4210, Gold Coast).
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.

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10 Steps to a More Relaxed Pregnancy

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