Questionnaire in English to Kati

Questionnaire to Katalin Alexáné Topál, IBCLC

Name of mother:

Age of mother:

Home address:

Phone number:

E-mail address

Name of baby:

Birth date:

Birth place/hospital:

Gestation week

Birth weight:

Lowest weight (which day):

Current weight:

Is this baby your first child? If not, how many other children do you have?

Did you breasfeed your other children? How long?

Name and phone number of baby’s pediatrician:

Name and phone number of baby’s area health visitor:

Method if delivery:
 vaginal programmed cesarean section emergency cesarean vacuum extraction"

Did you get during labour and delivery:
 painkiller anaesthetics epidural intravenous fluids

Did you breastfeed your baby in the delivery room?
 yes no

If not, when did you first breastfeed?

Did you room-in with your baby in the hospital? (24-hour, only during the day)

How often did you breastfeed?

Did the baby receive any of the following:
 water tea formula

Did you use any of the following:
 pacifier bottle nipple shield

Was you baby jaundiced? If yes, what treatment did your baby receive?

Did your breasts grow during pregnancy? Did you breasts grow after delivery?

Do you have any of the following:
 thyroidgland disorder policisticovarium syndrome diabetes menstrual disorders before pregnancy depression

Any other illnesses?:

Have you had breast surgery or injury?

Do you take medications or vitamins?

Do you use herbs to increase your milk supply?

Do you smoke?
 yes no

Do you take contraceptives?
 yes no

How often and how long do you breastfeed your baby?

Do you exclusively breastfeed your baby or do you give your baby water, tea, fruit juice or formula?

Do you breastfeed from one breast or from both breasts during a breastfeeding session?

Do you weigh your baby’s milk intake? (weight before and after feedings) If yes, how much is the intake?

How many wet diapers does your baby have in 24 hours?

What colour is the urine?

How many bowel movements does your baby have in 24 hours?

What colour is the stool?

Do you feel pain during breastfeeding?

Are your nipples injured?
 yes no

Do you give your baby a bottle or a pacifier? Do you use a nipple shield?

Do you pump?
 regularly occasionally no

What do you find most worrying in the current situation?

What dou you expect from me?

Thank you for your cooperation!