Infant Questionnaire Name First Last Birth Date Today's Date Medical problemsSex Male Female Present WeightBirth HospitalBirth Complications Vaginal Birth C-section Birth No Complication Birth ComplicationsElaborateAre you presently breastfeeding? Yes No If no, how long since you stopped?Was your infant premature? Yes No If yes, how many weeks?Has your infant experienced any of the following? Shallow latch at breast or bottle Gumming or chewing your nipple when nursing Falls asleep while eating Pacifier falls out easily, doesn’t like, won’t stay in Slides or pops on and off the nipple Milk dribbles out of mouth when nursing/bottle Colic symptoms / Cries a lot Short sleeping requiring feeding every 1-2 hrs Reflux symptoms Snoring, noisy breathing or mouth breathing Spits up often? (Amount/Freq) Clicking or smacking noises when eating Gagging, choking, coughing when eating Feels like a full-time job just to feed baby Gassy (toots a lot) / Fussy often Nose congested often Poor weight gain Baby is frustrated at the breast or bottle Hiccups often How long does baby take to eat? Lip curls under when nursing/taking bottle How often does baby eat? Please check & elaborate as needed. Spits up often?Amount/FreqHow long does baby take to eat?How often does baby eat?Is your infant taking any medications? Reflux Thrush Name of medicationHas your infant had a prior surgery to correct a tongue or lip tie?If yes, when, where, and by whom?Do you have any of the following signs or symptoms? Creased, flattened or blanched nipples Poor or incomplete breast drainage Lipstick shaped nipples Infected nipples or breasts Blistered or cut nipples Plugged ducts / engorgement / mastitis Bleeding nipples Using a nipple shield Pain on a scale of 1-10 when first latching Pain (1-10) during nursing Baby prefers one side over other (R/L) Please check & elaborate as needed.Pain on a scale of 1-10 when first latchingPain (1-10) during nursingPediatricianPhoneLactation consultantPhone
