BOTTLE REFUSAL QUESTIONNAIRE
Teresa Munguia, IBCLC, RLC
teresaibclc@loveinleche.com
(408) 821-4462
NAME
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DOB
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
FEEDING HISTORY
Baby's feedings are currently (Choose all that apply)
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Breastfeeding/latching
Bottle feeding pumped milk
Bottle feeding pumped milk and formula
Bottle feeding formula
Syringe feeding
Finger feeding
Cup feeding
Spoon feeding
Fortified breast milk or formula
Thickened breast milk or formula solids
Baby led weaning
Have you felt with any of the following challenges with this baby?
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Low milk supply
Oversupply and/or Overactive letdown
Tongue and/or lip tie
Breast refusal or nursing strike
Nipple shield use
Nipple damage
Colic
Baby not gaining well
Dairy or other food sensitivity
Reflux
Laryngomalacia or Tracheomalacia
Other
Has baby ever taken a bottle? If so, tell me when/why and how it went.
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Which brands of bottle have you tried already?
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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.
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Is there anything you think might be contributing to your baby not taking a bottle well at this point?
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CURRENT FEEDING ISSUES OR CHALLENGES
Pacifier Use?
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Yes, no preference for style/type
Tried it, baby won't take it/"hates it"
Baby will keep pacifier in mouth
Never tried a pacifier
Baby will not keep pacifier in mouth
Yes, but will only take one specific pacifier
Used to take it but won't anymore
Breathing or swallowing challenges
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Yes
No
Has tongue tie been mentioned/checked for/diagnosed/treated?
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Yes
No
History of oral trauma?
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Yes
No
Choking/Coughing/Sputtering?
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Yes
No
Were there any breastfeeding issues in the early days?
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Yes
No
What happens when you try to give the baby the bottle now?
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