Booking Forms

Please complete the following required forms prior to your Red Gate Clinic appointment.

BOOKING FORMS

Below you will find the required booking forms for you to complete prior to your Red Gate Clinic appointment:

BREASTFEEDING ~ Consent Form
BREASTFEEDING ~ Medical History Form

BOWEN ~ Consent Form
BOWEN ~ Medical History Form

BREASTFEEDING ~ Consent Form

Lactation Consultation, Use of Techniques, and Assessment *

I give permission for the lactation consultant to do all of the following

A lactation consult usually includes: * Visual & physical assessment of a mothers breasts and infants mouth * Observation of mother & baby feeding * Demonstration of techniques for improving breastfeeding & sometimes use of breastfeeding equipment

I understand that I should consult my GP re the medical care of my baby & self. *

Yes I understand

I give permission for information on my care to be given to my GP, Obstetrician, Paediatrician, Midwife, Child health nurse, health insurance or other allied health care provider where necessary to provide holistic care or insurance claim. *

I give permission for Sue Barford from Red Gate Clinic to take photos during my consult for purposes of assessment and my coaching reference in and after my consult. *

I give permission for Red Gate Clinic to use identified information/photos from this consult to further the knowledge of breastfeeding through education in presentations or case studies. In this instance I understand these images belong to Sue Barford. *

Mother's Name *

First

Last

Email *

(Red Gate Clinic to Complete) Lactation Consultation Details & Notes

BREASTFEEDING ~Medical History

Pre-Birth History

Appointment Date

Mother's Name *

Address

Mobile

Email *

Partner's Name *

Other Children

Ages, duration of feeding, any problems?

What is your EDD

How many weeks gestation are you?

Briefly indicate the reasons or reasons for your visit?

Past Medical History (Particularly PCOS, thyroid, infertility, diabetes)

CURRENT MEDICAL HISTORY

Past Surgery (particularly breast, thyroid or gynecological)

Pregnancy Issues? (Particularly gestational diabetes, thyroid, anemia, High BP, Prem labor)

Are you currently taking any medications or supplements?

Do any of these apply to you?

Special Diet?
Vegetarian?
Trying to lose weight?

POSTNATAL HISTORY

Your Baby's Name

Baby's DOB

Gestation weeks at birth

Current Age

Labor Summary (induction, pain relief, emergency)

Birth (Forceps, Vacuum, Caesarian)

Any issues for baby at birth?

Baby concerns (incl. jaundice, blood sugar, other medical)

Did baby have any of following?

Breathing Problems
Fever
Jaundice
Low Blood Sugar
Meconium Aspiration
Suction
None
Other - List below
Medications - List below

Other or medications? Please list.

How soon after delivery were you able to put baby to breast?

While in hospital, how many times in 24 hrs were you feeding?

Under 8
8-12
Over 12

While in hospital what was the longest time between feeds - list Day and Night

How is Feeding Going?

Current feeds in 24 hrs

Under 8
8-12 times
Over 12

Longest time between feeds - list each for Day and Night

How long each breast?

Is baby currently having extra fluid?

No
Yes - How Much?

If Yes, How Much?

In past 24 hours what is the colour, smell, consistency & number of nappies?

Is baby content & sleeping between feeds?

Never
Occasionally
Often

Dummy?

Never
Occasionally
Often

Any current concerns (please tick )

Baby always hungry
Prefers one breast
Not Interested
Cracked / Bleeding nipples
Nipple pain
Breast pain
Painful full breasts
Not enough milk
None

Are you using?

Hand expression
Pump
Breast cream
Breast / Nipple shield
None
Other

Other? Please list

Bowen Therapy Session

Prior to your Bowen Therapy appointment please fill out the below required forms.

Bowen Therapy/Treatment ~ Consent Form

Your Bowen Treatment Consent *

I give permission for the therapist to do all of the following

* History and assessment of your current situation * Discussion on appropriate follow up and exercises if necessary *Bowen therapy treatment as discussed

Bowen is a natural therapy and therapists can’t diagnose or prescribe. *

I understand that I should consult my GP regarding medical care.

I give permission for Sue Barford to use information and photos from consults to complete Bowen research or case studies. *

No identifying information will be used.

Your Name *

First

Last

Today's Date

Email *

(Red Gate Clinic to Complete)

BOWEN THERAPY/TREATMENT ~ Client Information

Client Information

Name *

First

Last

Birth Date / Age

Residential Address

Mailing Address

Email *

Home Phone

Mobile

Health Fund Name

Your GP

Your Occupation

Physical Activity / Sport

Are you a smoker?

If you drink alcohol, how many drinks daily/weekly?

Recent illness / operations? Please list and date.

Please outline any ongoing medical conditions

What medications do you take and what are they for?

Do you have high or low blood pressure?

High blood pressure
Low blood pressure
Normal

Are you pregnant?

Please detail any fractures/dislocations

Do you have any implants, replacements or reconstructions, please list and date?

Can you tell me more about the issue or issues you are seeking Bowen for?

How long ago did this start?

What other treatment have you tried or currently having?

What are your expectations of Bowen treatment for this issue?

From where or who did you hear about Red Gate Clinic?

Would you like to receive info about Bowen and specials in our newsletter? *