Postnatal Client Questionnaire

This form is to help me to get to know you and your family a bit better prior to our session. It helps me to tailor our session specifically to you. There is no pressure to share anything you don’t want to, and all questions are optional except for your contact information.

All responses and information shared during our discussions are strictly confidential and all paperwork including this completed form are kept in accordance with GDPR regulations. Please complete and return this form a minimum of 24 hours before your first session to enable me time to prepare for our time together. If you experience any issues with this form, please email me at info@themilkhub.co.uk

Your name *

First

Last

Are you attending a face-to-face consultation or a virtual consultation?

Face-to-face consultation (please ensure you complete the Covid-19 questions at the end of the form)
Virtual consultation

What are your preferred pronouns for yourself and your family?

Your email address *

Your telephone number *

Your address *

If you have booked a home visit, please provide details for parking arrangements.

What is the name of your baby/babies?

For clients with more than one child, this section relates to the baby or babies you are currently feeding in the case of multiples. If you are tandem feeding - amazing! Please detail the names of all the children you are feeding.

How old is your baby/babies now? If under 6 months, please list in weeks.

As above, if you are feeding more than one child, please include all of their ages in this section.

What is the name of your partner/supporter?

First

Last

What is your relationship to your named partner/supporter?

E.g. husband, wife, partner, friend, parent, etc.

Will your partner/supporter be attending our session too?

If you/your partner have older children or step children, please let me know their names and ages.

At what gestation was baby born?

E.g 40 weeks

How was baby delivered?

Vaginal delivery - no assistance
Vaginal delivery with intervention - e.g forceps, Emergency c-section
Planned/elective c-section

Can you tell us a little about your labour and delivery? How do you feel about that experience?

Things that are helpful here are if you were induced, if you received any medication during labour, and if there were any interventions.

Were you and baby/babies separated at all following the birth?

E.g. If one or both of you were poorly, for example if baby went to NICU.

Was your pregnancy considered high risk?

If your pregnancy was considered high risk, please share as much detail as you would like to around the reason for this classification.

Did you plan to/did you use any Hypnobirthing techniques during labour?

Can you tell us a little about how feeding is going?

How your feeding journey has been so far?

How many heavy wet and how many dirty nappies does your baby/babies have in 24 hours typically?

Heavy wet means soaked nappies, and dirty means a stool larger than a £2 coin.

What colour are their stools?

How are you feeding your baby/babies at the moment?

E.g. exclusively breastfeeding, exclusively pumping, combi-feeding or exclusively formula feeding. Please include as much detail as possible around what a typical feeding day looks like, e.g. how many direct breastfeeds baby is having, and how many bottles for example. We support however you choose to feed.

If applicable to your feeding journey - are you expressing at the moment? If so, why did you decide to start expressing and how frequently are you pumping?

How many feeds is your baby/babies typically having in 24 hours?

Have there been any concerns around weight gain for your baby/babies?

If you are directly breastfeeding, do you experience any pain during a feed? Are your nipples ever misshapen or squished at the end of a feed? They may appear to be the shape of a new lipstick.

If you are not breastfeeding, please feel free to skip this question.

How do you feel about feeding at the moment?

How does your partner/supporter feel about the feeding situation at the moment?

If you have older children, please share a little information about your previous feeding journey?

Are there any health concerns for you or your baby?

E.g. Previous breast surgery, fertility or hormonal concerns, heart conditions, diabetes, tongue-tie or other oral concerns.

Is there anything specifically worrying you about feeding at the moment that we haven't covered already in this section?

Are you familiar with mindfulness tools and techniques such as journaling, affirmations and guided relaxations?

Are you open to exploring mindfulness tools to support you with your feeding journey?

Are there any other services or professionals you as a family are currently working with? *

For example; Early Help, Perinatal Mental Health, Childrens Social Care, Home Start, Your Family, Infant Feeding Team etc.

If you have selected YES to the above question, please let us know which services or professionals you are currently work with.

Are there any specific anxieties, concerns or feelings you are experiencing at the moment that may be helpful to explore with mindfulness techniques?

Is there anything else you'd like to share with us?

Thank you for taking the time to complete the questionnaire, I know it is quite long! The more detail I have prior to the session means the more time we can focus on tools and techniques for you.

By completing and submitting this questionnaire you are giving permission for The Milk Hub to collect and process the above information including any personal information as defined under GDPR regulations, and in line with both our legitimate interests. All information you supply is held in the strictest confidence and not shared with any third parties without your consent. The only exception to this is if we are required to disclose information to another agency or service in line with a safeguarding concern. Completing and submitting this questionnaire also acknowledges that you accept the Privacy Notice, Terms and Conditions and Safeguarding Policy listed on The Milk Hub website. *

I agree

If I am attending a face to face consultation, I confirm the following information:

No one in my household (including myself) is experiencing any Covid-19 symptoms
No one in my household (including myself) has had contact with anyone with Covid-19 in the last 14 days
No one in my household (including myself) has been asked to self-isolate
No one in my household (including myself) has travelled abroad within the last 14 days

You will be asked to confirm the above information again, the day before your appointment. In the event of one or more of the above conditions not being met, a face-to-face appointment will not be able to take place. A virtual appointment will be offered to you at the same time.

Postnatal Client Questionnaire

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