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.*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?*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*Name of Baby's Pediatrician*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 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?*YesNoPlease describe.*