Lactation questionnaire

Mom's First & Last name

Mom's age

Baby's name

If case of multiples, fill out the questionnaire for each baby separately

Are you taking any medication/herbs/supplements?

Did you notice breast changes during pregnancy?

nipple color/sensitivity, larger size of breast

Place of birth (city/name of clinic)

What # of birth is this?

Baby's gender

Boy

Girl

Baby's birth weight

Baby's birth weight loss after birth

Baby's date of birth

Week of gestation

Estimated Due Date (EDD)

Month

Day

Year

Supplemental feeding at hospital

No

Yes (explain)

If "yes" indicate - formula/beast milk; bottle/finger feeding/cup/SNS

# of wet and soiled diapers per 24 hrs

Bottle or pacifier present? For how long?

All known weight measurements + dates

Can you hear baby swallowing during feeding?

Tongue tie and/or other facial-jaw defects

Apgar score at birth

Other health conditions of baby

Complaints in your own words

Photo of each nipple & frontal photo of both breasts

Images are strictly confidential and are deleted immediately after evaluation