Intake Form - Dorle Verrinder

First Name (Mother)

Surname (Mother)

Date of Birth (Mother)

Mobile Telephone

Medical Aid

Medical Aid Number

Dependent Number

Name and relationship of other(s) expected to attend the consultation with you

Physical Address

City

Street and Number

Country

Your baby's name

Your baby's (expected date of birth)

Your baby's weeks of gestation at birth

Sex of your baby

Male Female Not yet born and not yet known

Other...

Please elaborate on any ticked answers in the previous question.

Have you ever had any breast surgery or trauma? If so, please elaborate.

Please list all chronic and acute medication you are using

Do you have older children? How many? And what are their ages?

How long have you breastfed each of your older children?

Please elaborate on your past breastfeeding experiences. What were your difficulties and how did you overcome them, or not?

How would you describe your pregnancy?

Please describe any breast changes you may have experienced during and after your pregnancy.

Describe your birth experience. Please mention any of the following if applicable: Caesar/ epidural/ induction/ medication/ intravenous fluids/ other birth interventions.

When and how was breastfeeding initiated after birth?

Have you experienced sore/ cracked/ damaged/ bleeding nipples? If so, please elaborate.

Any unrelieved breast fullness / engorgement? Please elaborate.

Any persistent breast pain? Please elaborate.

Do you perceive your breast(s) or nipple(s) to be unusual in any way? If so, please elaborate.

Any lesions/rash on your breast or nipple (e.g. herpes, varicella)? If so, please name or elaborate.

How have you been coping since the birth of your baby, and how are you coping right now?

Please jot down the pattern of your baby's growth/ weight gain (e.g. birth 3.2kg, 3days 3kg, 7 days 3.2kg, 6weeks 4.5kg etc...)

Pattern of your baby's wet nappies in 24 hours?

Please elaborate on your use of any of the following: dummies, bottles, artificial nipples, supplements?

Please indicate if any of the following are applicable to your baby:

Please elaborate on any of your ticks in the previous question.

Please describe any other concerns you may have and the reason for requesting the consultation.

Consent

I hereby give permission for Dorle Verrinder, Registered Dietitian and Lactation Consultant, to share pertinent information about this consultation with other medical professionals involved in my care if necessary

Please provide the name of your paediatrician or general practitioner including their telephone number and/or email address:

Name of Doctor

Telephone of Doctor

Email of Doctor

I understand that: One or more follow-up visits may be required. My credit card will be charged after the consultation. There is a no-show or late arrival fee of N$250 if a consultation is not cancelled within 4 hours.

I have read and understood the above, and agree to be seen for lactation support by Dorle Verrinder.

Thank you for your time. Virtual consultations usually take 1 hour.

If you are consulting me regarding latch, suck or feeding issues, then I would like to observe a breastfeed during the consultation but that does not mean you should let your baby go hungry. If he or she is hungry in the 1-2 hours before we speak, feed just enough to keep your baby calm. Ideally have your baby in skin-to-skin contact during the consultation, with a blanket over you and your baby.

If you need help with pumping, or milk expression, please have your pump available during the consult.

It can help to have a person close to you, like a partner or friend or parent, who supports you with your baby, join the consultation, if you feel comfortable with that.

I look forward to speaking with you soon.
Warmly,
Dorle

Pre appointment intake form