Please complete the questionnaire below before your Breastfeeding Consultation "*" indicates required fields Name* First Last Are you currently taking any medication?* Yes No Have you ever had breast surgery?* Yes No What is your baby's date of birth?* MM slash DD slash YYYY 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?* Yes No Was your delivery an assisted vaginal birth?* Yes No Was your delivery a planned C-Section?* Yes No 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?* Yes No Are you supplementing with formula or ebm?* Yes No Would you like to discuss latching issues in this consultation?* Yes No Would you like to discuss supply issues in this consultation?* Yes No Would you like to discuss baby's disinterest in the breast?* Yes No Would you like to discuss pain while feeding in this consultation?* Yes No Would you like to discuss pain in your breast or nipples in this consultation?* Yes No NameThis field is for validation purposes and should be left unchanged.
