Infant Questionnaire
Parent Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Patient
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
Due Date
*
-
Month
-
Day
Year
Date
Today's Date
*
-
Month
-
Day
Year
Date
Pediatrician
*
Phone Number
*
-
Area Code
Phone Number
Lactation Consultant
Yes
No
Who?
Phone Number
*
-
Area Code
Phone Number
Who referred you to us?
*
Pregnancy/Birth
History
Birth Hospital:
*
How did you give birth?
*
Vaginal
C-section
Birth Weight:
*
Present Weight:
*
Any complications with pregnancy or birth:
*
Are you presently breastfeeding?
*
Yes
No
How long since you stopped?
*
Medical History
Is your child taking any medications?
*
Does your child have any allergies?
*
Did your child receive the Vitamin K shot at birth?
*
Yes
No
Does your child have any heart disease?
*
Has your child had any surgery?
*
Has your child had a prior surgery to correct the tongue or lip tie? If yes, when, where, and by whom?
*
Has your child seen a chiropractor or CST?
*
Yes
No
When, where and by whom?
*
Have you seen a feeding team/feeding specialist or OT/PT?
Yes
No
If so, Who?
Has your child experienced any of the following (check all that apply)
Pain when first latching (1-10):
*
Pain during nursing (1-10):
*
Does your child prefer one side over the other:
*
Yes
No
Which side?
*
Right
Left
Do you use a nipple shield?
*
Yes
No
How many times a day do you breastfeed?
*
How long on each side?
*
What are your main concerns (reasons for seeking treatment)?
*
Submit
Should be Empty: