Date and time of consultation
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Day
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Month
Year
Date Picker Icon
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01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
10
20
30
40
50
Minutes
Family E-mail
The following information has been reviewed:
Maternal & Infant questionnaires
Doctors Notes
Discharge summary
QH viewer
Verdi
Mothers UR
Mothers First Name
Current feeding practice
Model of care
Private
MGP
Public inc HCP
Name of Midwife
Current feeding practice
Breastfeeding
Expressing
Breastfeeding and expressing
Breastfeeding and Formula
Formula
Suppressing
Inducing lactation (primary)
Inducing relactation
Other
Baby's First Name
Comment
Previously breastfed another infant?
Yes
No
How would you describe this experience?
Positive
Neutral
Negative
Significant History
Pregnancy changes
Breast changes post partum
Breast changes post partum
Physiological Engorgement
Pathological Engorgement
Not asked
Other
Postnatal changes
Current feeding concerns as expressed by parents
Current feeding concerns as expressed by parents
Low supply
Over supply
Attachment difficulties
Breast refusal
Unsettled baby
Weaning off shield
Expressing
Reducing formula
Slow weight gain
Tongue tie
Mastitis
Blocked duct
History of surgery
General education
Anxiety
Other
Breast examination
Breast Assessment
Nipple assessment
Breast Assessment
Lactating normally
Dermatitis
Engorged
Hypoplastic
Large pendulous breasts
Low supply
Previous surgery
Inflammed
Other
Nipple assessment
Everted
Inverted
Flat
Intact
Damaged
Bleb
Colour change
?thrush
Other
Type of nipple damage
Nil
Grazed
Cracked
Bleeding
Infected
Other
Area of nipple damage
Nipple tip
Nipple body
Nipple base
Areola
Type of nipple damage
Comments re nipples
Rate pain
1
2
3
4
5
6
7
8
9
10
No Pain
Worst Pain can imagine
1 is No Pain, 10 is Worst Pain can imagine
Maternal temperature?
Yes
No
Not known
Highest maternal temp
Details re inflammation
Mild
Moderate
Severe
Redness
Swelling
Diagnosis
Blocked duct/s
Mastitis
Abscess
Other
Findings
Is the woman less than 2 weeks PN?
Yes
No
Does the woman have a mental health history?
Yes
No
EPDS
If over 13 refer to triage form
Q10 Response: The thought of harming myself has occurred tome
Yes
Quite often
Sometimes
Hardly ever
Never
During the past month have you often been bothered by feeling down, depressed or hopeless?
Yes
No
During the past month have you often been bothered by little interest or pleasure in doing things?
Yes
No
Is this something you feels you need or want help with?
Yes
No
Summary and plan
Lactation Consultant
Please Select
Moina Mitchell
Stacy Jukes
Kathleen Goldsmith
Julie Germain
Loretta Anderson
Christine Adams
Sam Foster
Robin Day
Kate Maynard
Megan Henry
Susan Childs
Sarah Moulton
Maria Oliveri
Other
Other clinician
Designations
CM
CN
RM
RN
IBCLC
CHN
Email address of clinician
Please Select
Moina.Mitchell@mater.org.au
Stacy.Jukes@mater.org.au
Kathleen.Goldsmith@mater.org.au
Julie.germain@mater.org.au
Christine.Adams@mater.org.au
Loretta.Anderson@mater.org.au
sam.foster@mater.org.au
robin.day@mater.org.au
kate.maynard@mater.org.au
megan.henry@mater.org.au
susan.childs@mater.org.au
Sarah.Moulton@mater.org.au
Maria.Oliveri@mater.org.au
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Designations
Parent 2's First Name
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