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Breastfeeding Center of Pittsburgh

4070 Beechwood Blvd
Pittsburgh, PA 15217

Breastfeeding Center of Pittsburgh

Home
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Pre-Visit

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?*
- Yes
- No
What 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?*
- Yes
- No
Name 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?*
- Yes
- No
Secondary 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?*
- Yes
- No
Name 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?*
- Yes
- No
Please describe the reason for pumping, and how often you pump.*
Is baby currently receiving any pumped milk or formula in addition to breastfeeding?*
- Yes
- No
Please estimate how much, how often, and tell us if it's pumped milk or formula.*
Did you have any pregnancy-related complications?*
- Yes
- No
Please describe.*
Weeks gestational age at time of delivery*
Name of OB/Midwife*
Where was baby born?*
Type of delivery*
- Vaginal
- Cesarean
- Vacuum/Forceps Assisted
Did you have any delivery complications?*
- Yes
- No
Please describe.*
Did you begin breastfeeding in the hospital?*
- Yes
- No
Did you pump in the hospital?*
- Yes
- No
Are 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?*
- Yes
- No
Please 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?*
- Yes
- No
Did your baby have any complications or procedures following birth, or do they have any current medical issues?*
- Yes
- No

Reach all of our offices at: 412-246-4726

Squirrel Hill/
Greenfield

4070 Beechwood Blvd
Pittsburgh, PA 15217

Cranberry/
Seven Fields

671 Castle Creek Dr
Seven Fields, PA 16046

Pleasant Hills

810 Clairton Blvd
Pittsburgh, PA 15236

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Home
Clinician Resources
Pre-Visit
Offices

Our Practice
Team
BF 101
Mom Stories
- Featured Stories
- Testimonial Archive
Classes
Your Visit