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Breastfeeding questionnaire

Liliana Williams-Cantor BA, IBCLC International Board Certified Lactation Consultant BREASTFEEDING QUESTIONNAIRE TODAY’S DATE_________________________________________________________
MOTHER’S NAME_____________________________DOB________ INFANT’S NAME__________________________________DOB__________________
IN YOUR OWN WORDS DESCRIBE ANY FEEDING PROBLEMS THAT CONCERN YOU:
____________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
FAMILY HISTORY
DOES ANYONE ON EITHER SIDE OF THE BABY’S FAMILY HAVE ANY OF THE FOLLOWING? (CIRCLE) allergies to foods environmental allergies asthma eczema
hay fever breast cancer diabetes genetic disease thyroid disease other___________________________________________________________________________________________
WHAT AGE WERE YOU WHEN YOU HAD YOUR FIRST MENSTRUAL PERIOD? ________________________ REGULAR OR IRREGULAR
WAS THIS YOUR FIRST PREGNANCY? (CIRCLE) yes no if no, how many pregnancies?_________how many children?_____________did you breastfeed your other children?__________________________
WHICH OF THE FOLLOWING FAMILY PLANNING METHODS ARE YOU USING OR DO YOU PLAN TO USE? (CIRCLE) Norplant birth control shot barriers birth control pills
vasectomy natural family planning/rhythm tubes tied none
WILL YOU BE RETURNING TO WORK? (CIRCLE) yes no WHEN?________________________________________________FULL TIME?___________________PART TIME______________________
PREGNANCY AND BIRTH HISTORY
DOES YOUR BABY HAVE ANY KNOWN HEALTH PROBLEMS? _______________________________________________________________________________________________________________________
IS THE BABY CURRENTLY ON ANY MEDICATIONS?_________________________________________________________________________________________________________________________________
ARE YOU TAKING ANY OF THE FOLLOWING? (CIRCLE) prenatal vitamin-mineral iron antihistamines cold remedies antibiotics aspirin laxatives
diuretics/water pills antacids birth control pills pain pills diet pills herbs other_______________________________________________________________________
HAVE YOU EVER HAD ANY OF THE FOLLOWING PROCEDURES RELATED TO YOUR BREAST? (CIRCLE) biopsy lumps implants breast reduction surgery nipple problems
other_______________________________________________________________________________________________________________________________________________________________________________


DO YOU PRESENTLY HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? (CIRCLE) anemia allergy/asthma diarrhea (chronic) heart disease
diabetes hepatitis venereal disease high blood pressure liver disease thyroid disorders miscarriages hemorrhoids cancer
infertility abortions depression sexual abuse abnormal pap smear constipation eating disorder kidney/bladder disease or infection
yeast infections tuberculosis polycystic ovarian syndrome other______________________________________________________________________________________________
DID YOU HAVE ANY OF THE FOLLOWING DURING THIS PREGNANCY? (CIRCLE) premature labor gestational diabetes high blood pressure nausea/vomiting-severe
anemia fever urinary tract infection medications other___________________________________________________________________________________________________________
DID YOU HAVE ANY OF THE FOLLOWING DURING THIS LABOR AND DELIVERY? (CIRCLE) premature rupture of membranes
drugs to control pain drugs to control high blood pressure epidural fever antibiotics
drugs to induce or speed labor-if so how long during labor was this drug administered?________________________________________hours
hemorrhage-if so how much blood was lost_____________________pints, other_______________________________________________________________________________________________________________
WHAT TYPE OF DELIVERY DID YOU HAVE WITH THIS BIRTH? (CIRCLE) vaginal emergency c-section planned c-section GESTATIONAL AGE OF BABY AT BIRTH?______________WEEKS
DID YOU HAVE ANY OF THE FOLLOWING WITH THIS BIRTH? (CIRCLE) total labor longer than 30 hours episiotomy or tear pushing stage longer than 2 hours breech presentation
tear that involved the rectum (3rd or 4th degree laceration) forceps delivery vacuum extraction other______________________________________________________________________
DID YOU EXPERIENCE ANY POSTPARTUM COMPLICATIONS? (CIRCLE) urinary/other infections low blood pressure high blood pressure excessive bleeding or hemorrhaging
other_______________________________________________________________________________________________________________________________________________________________________________
DID THE BABY HAVE ANY OF THE FOLLOWING AFTER BIRTH? (CIRCLE) breathing difficulties high hematocrit low blood sugar meconium aspiration jaundice
(highest bili level____________) other_____________________________________________________________________________________________________________________________________

WHAT WAS YOUR BRA SIZE: BEFORE PREGNANCY_________ NOW________ CHANGES SINCE THE BIRTH? hard/engorged heavy warm leaking no changes
BREASTFEEDING HISTORY
HOW OLD WAS YOUR BABY WHEN YOU FIRST REALIZED THAT YOU WERE HAVING BREASTFEEDING DIFFICULTIES?_______________________________________________________________
HAVE YOU USED ANY BREASTFEEDING SUPPLIES OR PUMPS?____________________________________________________________Type of PUMP_____________________________________________


HAS YOUR BABY BEEN SUPPLEMENTED WITH ANY OF THE FOLLOWING? NONE water formula expressed breastmilk TYPE OF FORMULA_________________________________
IF SO, HOW WAS THE BABY SUPPLEMENTED? feeding tube finger feeding cup feeding bottle TYPE of BOTTLE_____________________________________________________________
IF SUPPLEMENTS HAVE BEEN USED, HOW OFTEN IN PAST 24 HOURS? __________________________________HOW MUCH PER FEEDING?__________________________________________________
HOW MANY TIMES IN THE PAST 24 HOURS HAVE YOU BREASTFED YOUR BABY? (CIRCLE) less than 6 times less than 8 times 8-10 times more than 12 times
ARE YOU EXPERIENCING ANY OF THE FOLLOWING? (CIRCLE) latch-on difficulties engorgement sleepy baby sore nipples preference for one breast
baby not interested cracked/bleeding nipples breast pain feeling that there is not enough milk baby crying excessively baby always seems hungry
other______________________________________________________________________________________________________________________________________________________________________________
IS THE BABY CONTENT OR SLEEPING BETWEEN FEEDINGS? (CIRCLE) never occasionally often
WHAT IS THE LONGEST TIME YOUR BABY HAS GONE BETWEEN FEEDINGS? DAY:_____________________________________ NIGHT:__________________________________
WHO DECIDES WHEN THE FEEDING IS OVER? (CIRCLE) Mother or Baby HOW LONG DOES BABY NURSE AT BREAST?_______________________ ONE BREAST OR BOTH BREAST
HOW MANY MONTHS DO YOU WISH TO BREASTFEED YOUR BABY? 1 MONTH 2-3 MONTHS 3-6 MONTHS 6-9 MONTHS 12 MONTHS LONGER THAN 12 MONTHS
ARE YOU PRESENTLY USING A PACIFIER? yes or no
HOW OFTEN? _________________________________________________________________________________________________________________
IN THE PAST 24 HOURS, HOW MANY? WET DIAPERS_________________ STOOLS_______________________ WERE THE STOOLS BIGGER THAN A TABLESPOON? yes no

Source: http://lilianawilliamscantoribclc.com/forms/Breastfeeding-Questionnaire.pdf

H:/office/texdocs/xl/otterloos_preferences.dvi

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Microsoft word - ecj1.doc

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