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 Your Visit. (Select all that apply.)* General breastfeeding guidance Nipple pain Difficulty with baby's latch Low milk supply Other Please Describe the "Other" Reason for Your Visit.*Is this your first baby?*YesNoWhat are the ages of your other children?*Do you have a history of breastfeeding issues with your other child(ren)?*Is Baby a Kids Plus Pediatrics patient?*YesNoName of Baby's Pediatrician*How did you hear about the Breastfeeding Center of Pittsburgh?*Parent's Name* First Last Parent's Date of Birth* Date Format: MM slash DD slash YYYY Parent's Mailing Address*Parent's Email Address*Best Phone # for Contact*Primary Insurance Holder's Name* First Last Primary Insurance Holder's Date of Birth* Date Format: MM slash DD slash YYYY Insurance Company Name*Insurance ID*Do you have secondary insurance?*YesNoSecondary Insurance Holder's Name* First Last Secondary Insurance Holder's Date of Birth* Date Format: MM slash DD slash YYYY Secondary Insurance Company Name* Date Format: MM slash DD slash YYYY Secondary Insurance ID* Date Format: MM slash DD slash YYYY Does baby have different insurance than the policy (or policies) already listed?*YesNoName of Insurance Holder for Baby's Different Policy* First Last Insurance Company Name for Baby's Different Policy* Date Format: MM slash DD slash YYYY Insurance ID for Baby's Different Policy* Date Format: MM slash DD slash YYYY 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?*YesNoPlease describe the reason for pumping, and how often you pump.*Is baby currently receiving any pumped milk or formula in addition to breastfeeding?*YesNoPlease estimate how much, how often, and tell us if it's pumped milk or formula.*Did you have any pregnancy-related complications?*YesNoPlease describe.*Weeks gestational age at time of delivery*Name of 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 shield At-the-breast supplementer (i.e., supplemental nursing system, syringe and feeding tube) None Do you have any drug allergies?*YesNoPlease list.*Check all that apply in YOUR medical history* Breast surgery and/or injuries Endocrine disorders (diabetes, thyroid, PCOS) Fertility issues History of pregnancy loss Mental health issues Smoking Other significant issues None of these Besides you and baby, please list who else lives in your home.*Are there any smokers in the home?*YesNoDid your baby have any complications or procedures following birth, or do they have any current medical issues?*YesNo