Breastfeeding Consultation Questionnaire

Name*

First Last

Are you currently taking any medication?*

Have you ever had breast surgery?*

What is your baby's date of birth?*

Please enter your baby's name*

First Last

What was your baby's gestation at birth (weeks)?*

What is your baby's age on day of appointment (months)?*

What is the reason for your consultation?*

Was your delivery a normal vaginal birth?*

Was your delivery an assisted vaginal birth?*

Was your delivery a planned C-Section?*

What was your baby's birth weight (kg)?*

What is your baby's most recent weight (kg)?*

How many hours after birth was your baby's first breastfeed?*

Are you exclusively breastfeeding now?*

Are you supplementing with formula or ebm?*

Would you like to discuss latching issues in this consultation?*

Would you like to discuss supply issues in this consultation?*

Would you like to discuss baby's disinterest in the breast?*

Would you like to discuss pain while feeding in this consultation?*

Would you like to discuss pain in your breast or nipples in this consultation?*

Name

This field is for validation purposes and should be left unchanged.