Pre-Visit Questionnaire To help us get the information we need, and to help make your visit go even smoother and faster, please fill out our Pre-Visit Questionnaire below. Baby's Name* First Last Baby's Date of Birth Date Format: MM slash DD slash YYYY Reason for Visit*Parent's Name* First Last Email Address*Best Phone # for Contact*Starting with birth weight, please list all official weights from your pediatrician’s office, including the date they were recorded.*In the last 24 hours, how many times did baby breastfeed?*Are you currently doing any pumping?*YesNoIs baby currently receiving any pumped milk or formula in addition to breastfeeding?*YesNoHow many bottles/ounces of supplement?*Expressed breast milk, or formula?*Did you have any pregnancy-related complications?*YesNoPlease describe.*Weeks gestational age at time of delivery*Mom's OB/Midwife*Where was baby born?*Type of delivery*VaginalCesareanVacuum/Forceps AssistedDid you have any delivery complications?*YesNoPlease describe.*Did you begin breastfeeding in the hospital?*YesNoDid you pump in the hospital?*YesNoAre you currently using any of these breastfeeding tools?*Nipple shieldAt-the-breast supplementer (i.e., supplemental nursing system; syringe and feeding tube)NoneDo you have any drug allergies?*YesNoPlease list.*Check all that apply in YOUR medical history.*Breast surgery and/or injuriesEndocrine disorders (diabetes, thyroid, PCOS)Fertility issuesMental health issuesSmokingOther significant issuesNone of theseBesides you and baby, please list who else lives in your home.*Are there any smokers in the home?*YesNo