PATIENT EVALUATION & MANAGEMENT FORM

BOTTLE REFUSAL QUESTIONNAIRE
Teresa Munguia, IBCLC, RLC

teresaibclc@loveinleche.com

(408) 821-4462
NAME*
DOB*

MonthDayYear
Date
FEEDING HISTORY
Baby's feedings are currently (Choose all that apply)*

Breastfeeding/latchingBottle feeding pumped milkBottle feeding pumped milk and formulaBottle feeding formulaSyringe feedingFinger feedingCup feedingSpoon feedingFortified breast milk or formulaThickened breast milk or formula solidsBaby led weaning
Have you felt with any of the following challenges with this baby?*

Low milk supplyOversupply and/or Overactive letdownTongue and/or lip tieBreast refusal or nursing strikeNipple shield useNipple damageColicBaby not gaining wellDairy or other food sensitivityRefluxLaryngomalacia or TracheomalaciaOther
Has baby ever taken a bottle? If so, tell me when/why and how it went.*
Which brands of bottle have you tried already?*
Is there a specific event or date by which you need baby to take the bottle? (I.e. back to work, special event, hospitalization, etc). Give as much detail as you'd like.*
Is there anything you think might be contributing to your baby not taking a bottle well at this point?*
CURRENT FEEDING ISSUES OR CHALLENGES
Pacifier Use?*

Yes, no preference for style/typeTried it, baby won't take it/"hates it"Baby will keep pacifier in mouthNever tried a pacifierBaby will not keep pacifier in mouthYes, but will only take one specific pacifierUsed to take it but won't anymore
Breathing or swallowing challenges*

YesNo
Has tongue tie been mentioned/checked for/diagnosed/treated?*

YesNo
History of oral trauma?*

YesNo
Choking/Coughing/Sputtering?*

YesNo
Were there any breastfeeding issues in the early days?*

YesNo
What happens when you try to give the baby the bottle now?*
Should be Empty:

BOTTLE REFUSAL QUESTIONNAIRE

FEEDING HISTORY

CURRENT FEEDING ISSUES OR CHALLENGES