Anamnesis form to Ibolya Rózsa, IBCLC

Anamnesis form

for Ibolya Rózsa, IBCLC

For appointment call: +36 30 583-4877

or e-mail: segits@iboly.hu

Please, do not submit this form before setting up an appointment.

By submitting this form you accept the Home Visit Consultation Terms and Conditions.

Thank you!

Just a reminder: when is our appointment? Parent's name Home address (where to visit)

Phone

e-mail

Baby's full name (use dash to separate if twins)

Baby's date of birth

Gestation

Does the baby suffer from any illnesses?

Weight at birth

Length at birth

Lowest weight? When?

Current weight

Number of siblings How successful your previous breastfeedings were, if any? Please, describe your recent breastfeeding problem.

Have you already consulted anyone else about this particular problem? Please, share the advice you received. Baby's pediatrician Pediatrician's contact details Health visitor's (védőnő) contact details

Do you have any problem with your thyroid (pajzsmirigy) function?

Do you have or have you ever had Policystic Ovarium Syndrome - PCOS?

(Tap button for positive answer)

Do you have diabetes?

Any other known illnesses?

Did your breast grow during pregnancy?

Have you had breast surgery?

Do you take oral contraceptives (pills)?

Do you have a history of depression?

Do you smoke?

Do you regularly take any medications or vitamins? Do you use herbs?

We are halfway through...

Any complications during your pregnancy? The hospital you delivered at

Method of delivery?

 vaginal 
							
 cesarean 
							
 spontaneous 
							
 forceps 
							
 vacuum 
							
 programmed cesarean

During labour and delivery, did you get?

 painkiller? 
							
 anaesthetics? 
							
 epidural? 
							
 IntraVenous fluids?

Did you breastfeed your baby in the delivery room?

If not, when did you breastfeed first?

How often did you breastfeed?

 Did you room-in with your baby in the hospital? 
						
 Were you together during nighttime? 
						
 Did you breastfeed during the night?

Did your baby receive water, tea or formula during your hospital stay?

water

tea

formula

Did you use bottle, pacifier (dummy) or nipple shield in the hospital?

bottle

pacifier

nipple shield

Was your baby jaundiced (yellowish skin due to hyperbillirubinaemia)?

If yes, what treatment did your baby receive?

How long after birth did you go home and what was the baby's weight at that time?

When did the problems start at home? How often does your baby nurse? Do you measure your baby's weight before and after nursings? Do you exclusively breastfeed or your baby gets...

Do you give your baby pacifier (dummy), bottle or use nipple shield?

pacifier

bottle

nipple shield

Do you pump? Number of wet diapers? Color of urine? Number of stools? Color of stools? Any injuries on your nipple? Is breastfeeding painful?

A few more questions...

What solution do you expect from me? How did you learn about me? Additional comments

Thank you.
See you soon.