MAKANA BREASTFEEDING QUESTIONNAIRE
Melissa Preitauer, IBCLC
TODAY’S DATE________________________
MOTHER’S NAME_____________________________________________ DOB_________________
INFANT’S NAME______________________________________________ DOB__________________
GESTATIONAL AGE OF BABY AT BIRTH?______________ weeks
BIRTH WEIGHT__________
APPROX. WEIGHT TODAY__________
DATE LAST WEIGHED? ___________
IN YOUR OWN WORDS DESCRIBE ANY FEEDING PROBLEMS THAT CONCERN YOU:
____________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
MEDICAL HISTORY
DO YOU PRESENTLY HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? (CIRCLE)
anemia asthma
eczema hay fever allergies to foods diarrhea (chronic)
constipation
heart disease
diabetes
hepatitis
venereal disease
high blood pressure
liver disease
thyroid disorders
miscarriages
infertility
depression
sexual abuse
abnormal pap smear cancer
eating disorder
kidney/bladder disease or infection
yeast infections
tuberculosis
breast cancer genetic disease
Other______________________________________________________________________________________________________
HAVE YOU EVER HAD ANY OF THE FOLLOWING PROCEDURES RELATED TO YOUR BREAST? (CIRCLE)
biopsy
lumps
implants
breast reduction surgery
nipple problems
Other______________________________________________________________________________________________________
ARE YOU TAKING ANY PRESCRIBED OR OVER-THE-COUNTER MEDICATIONS? (CIRCLE) prenatal vitamins
antihistamines cold remedies antibiotics aspirin
iron
laxatives
diuretics/water pills
antacids
birth control pills
pain pills diet pills herbs
Other____________________________________________________________________________
HOW IS YOUR DIET? (CIRCLE)
Balanced
HOW IS YOUR APPETITE? (CIRCLE)
DO YOU SMOKE?
Yes
No
High protein
Good
Low fat
Missing Meals
DRINK ALCOHOL? N/A
Vegetarian
Weight loss
Special diet
Poor Appetite
Occasional
Regular
DO YOU HAVE A HISTORY OF POLYCYSTIC OVARY SYNDROME (PCOS)?____________
DO YOU HAVE ANY OTHER CHILDREN?________ DID YOU BREASTFEED YOUR OTHER CHILDREN?_________
WHICH FAMILY PLANNING METHOD ARE YOU USING OR DO YOU PLAN TO USE? (CIRCLE)
Norplant birth control shot barriers birth control pills
vasectomy natural family planning/rhythm tubes tied
WILL YOU BE RETURNING TO WORK? Yes
No
WHEN?___________________
none
FULL or PART TIME
DID YOU HAVE ANY OF THE FOLLOWING DURING THIS PREGNANCY? (CIRCLE)
premature labor
gestational diabetes
high blood pressure
anemia
fever
urinary tract infection
medications
Other______________________________________________________________________________________________________
WHAT WAS YOUR BRA SIZE BEFORE PREGNANCY?_________ NOW? ________
ANY BREAST CHANGES SINCE GIVING BIRTH?
hard/engorged
heavy
warm
leaking
DID YOU HAVE ANY OF THE FOLLOWING DURING THIS LABOR AND DELIVERY? (CIRCLE)
premature rupture of membranes
drugs to control pain drugs to control high blood pressure
epidural
fever
no changes
antibiotics
DRUGS TO INDUCE OR SPEED LABOR? ___________________ DID YOU HEMORRHAGE? ___________________
WHAT TYPE OF DELIVERY DID YOU HAVE WITH THIS BIRTH? (CIRCLE)
vaginal
emergency c-section
planned c-section
DID YOU HAVE ANY OF THE FOLLOWING WITH THIS BIRTH? (CIRCLE)
total labor longer than 30 hours
episiotomy or tear
pushing stage longer than 2 hours
breech presentation
forceps
delivery
vacuum extraction
tear that involved the rectum (3rd or 4th degree laceration)
Other______________________________________________________________________________________________________
DID YOU EXPERIENCE ANY POSTPARTUM COMPLICATIONS? (CIRCLE)
urinary/other infections
low blood pressure
high blood pressure
excessive bleeding or hemorrhaging
Other______________________________________________________________________________________________________
DID YOUR BABY HAVE ANY OF THE FOLLOWING AFTER BIRTH? (CIRCLE)
breathing difficulties high hematocrit
low blood sugar meconium aspiration jaundice (highest bili level____________)
Other_______________________________________________________________
DOES YOUR BABY HAVE ANY HEALTH PROBLEMS?________________________________________________________
IS YOUR BABY CURRENTLY ON ANY MEDICATIONS? _______________________________________________________
BREASTFEEDING:
HOW OLD WAS YOUR BABY WHEN YOU FIRST REALIZED THAT YOU WERE HAVING BREASTFEEDING
DIFFICULTIES?_______________________________________________________________
ARE YOU EXPERIENCING ANY OF THE FOLLOWING? (CIRCLE) latch-on difficulties
engorgement sleepy baby
sore nipples
preference for one breast
baby not interested
cracked/bleeding nipples
breast pain
feeling that there is not enough milk
baby crying excessively
baby always seems hungry
Other______________________________________________________________________________________________________
HAVE YOU USED ANY BREASTFEEDING SUPPLIES OR PUMPS?______________________________________________
TYPE OF PUMP?_____________________________________________
HAS YOUR BABY BEEN SUPPLEMENTED WITH ANY OF THE FOLLOWING? (CIRCLE)
none
water
formula
expressed breastmilk
IF SO, HOW WAS YOUR BABY SUPPLEMENTED?
feeding tube
finger feeding
syringe
cup feeding
bottle
IF USING SUPPLEMENTS, HOW MANY TIMES IN 24 HOURS? __________________________________
HOW MANY OZ PER FEEDING?__________________________________________________
USING A PACIFIER?
Yes
No
HOW MANY TIMES IN THE PAST 24 HOURS HAVE YOU BREASTFED YOUR BABY? (CIRCLE)
less than 6 times
less than 8 times
8-10 times
more than 12 times
IS YOUR BABY CONTENT BETWEEN FEEDINGS? (CIRCLE)
never
occasionally
DO YOU HAVE TO WAKE YOUR BABY ALL THE TIME TO BREASTFEED? Yes
always
No
WHAT IS THE LONGEST TIME YOUR BABY GOES BETWEEN FEEDINGS?
DURING DAY:_____________________________________ NIGHT:__________________________________
WHO DECIDES WHEN THE FEEDING IS OVER? (CIRCLE) Mother
or
Baby
HOW LONG DOES BABY NURSE AT BREAST?_______________________ ONE BREAST OR BOTH BREAST
IN THE PAST 24 HOURS: HOW MANY?
WET DIAPERS_________________ STOOLS_______________________
WERE THE STOOLS BIGGER THAN A TABLESPOON?
WHAT COLOR ARE THE STOOLS? (CIRCLE)
Yes
No
black/tarry/meconium
yellow/seedy
orange
HOW LONG WOULD YOU LIKE TO BREASTFEED YOUR BABY?______________________
WHAT DOES HAPPY BREASTFEEDING LOOK LIKE TO YOU? WHAT IS YOUR GOAL?
brown
green