Infant Feeding Help - Intake Questionnaire

Please fill out the following form to help us understand your history and goals.

Parent 1

Have you been hospitalized in the last 12 months?
Are you currently suffering from a medical condition, illness, or injury?

Reason for visit

Please click all that apply.

Please provide point-form details for each issue above.

Baby's age & adjusted age (preemie) (baby 1, baby 2)

Birth pregnancy postpartum issues/trauma/

# of feeds in past 24 hrs

How many from:

  • Breast/chest

  • Bottle (my milk)

  • Bottle (donated milk)

  • Bottle (formula)

  • Supplemental Nursing System

  • Spoon feeding

  • Cup feeding

  • Syringe Feeding

  • Combo (e.g. SNS or syringe used at breast/chest)

Is baby being given water or other drinks besides milk or formula?

Is baby being given food other than milk or formula?

If you are breast/chest feeding:

  • does one side produce more than the other?

  • do you finish one side completely then switch to the other side?

What is your baby like after feedings?

Very limp, with floppy limbs

Sleepy

A little sleepy

Deeply sleepy

Asleep

What are your baby's feeding cues?

Can you feel or otherwise notice your letdown? (yes, no, I don't know, what is letdown)

Baby's behaviour when starting a feed:

  • Eager

  • Desperate

  • Shaking head side-to-side

  • Crying

  • Gape (mouth): Tiny, Middling, Pretty wide, Very wide

  • Calm

  • Sleepy

Waking baby to feed?

Avg nursing time

Hrs between daytime feeds

Hrs between nighttime feeds

Using pacifier?

Wet diapers in the last 24 hrs:

Diapers with stools:

Maternal appetite:

Have you seen any other healthcare professionals about these or other feeding issues?

If yes, what instructions did they give you?

Was baby separated from breast/chestfeeding parent (taken somewhere that the parent and baby could not connect in any way)?

Current infant weight:

What is your overall impression of your current feeding situation?

Thanks for completing your intake.