Patient Information
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Child Information
Child's Name
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DOB
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Age in Weeks
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Breast or Bottle Feeding
Breast
Bottle
Are You Wokring With a Lactation Consultant?
Yes
No
Lactation Consultant's Name and Phone Number
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Pediatrician's Name and Phone Number
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Has Your Child Been Evaluated for Tongue/Lip Tie?
Yes
No
If Yes, Type
Tongue
Lip
Both
Has Your Child Had a Franectomy?
Yes
No
If Yes, List Provider and Date of the Procedure
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Medications
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Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Contact Info
Mobile Phone
Email
Address
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Canada
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Bouvet Island
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Heard Island And Mcdonald Islands
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Iraq
Isle Of Man
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Korea, Republic Of
Kuwait
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Libyan Arab Jamahiriya
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Lithuania
Luxembourg
Macao
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Madagascar
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Malaysia
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Mali
Malta
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Monaco
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Spain
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Sweden
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Taiwan, Province Of China
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Thailand
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Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
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Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Parent Covid Question
Are You Fully Vaccinated Against Covid-19?
Yes
No
Baby Symptoms
Reflux/Colic
Difficulty Latching
Gumming or Chewing Breast
Gassy
Poor Weight Gain
Clicking While Feeding
Excessive Drooling
Choking on Milk
Popping off Breast/Bottle - Gasping For Air
Blisters on Lips or Gums
Extra Long Nursing Sessions
Sleep Troubles
Other Information
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Nursing Mothers Symptoms
Plugged Ducts
Compromised Milk Supply
Thrush/Mastitis
Cracked/Blistered/Bleeding Nipples
Other Information
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Tummy Time
Have you started Tummy Time?
Yes
No
How many times a day do you do Tummy Time?
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What is the average length of your Tummy Time session?
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Where is Tummy Time being done?
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Sleep
Where/how does baby sleep (ex. bassinet, swaddled, co-sleep etc.)?
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Frequency of waking during the night?
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How many times a day is baby napping? Where? For How Long?
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Feeding
Describe your everyday feeding experience:
Does baby have a preferred breast/feeding side?
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What is your feeding goal?
Other Questions
How many times a day/week does baby poop?
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What are your most used baby items (ex. Swing, bouncer, bumbo, jumper)? How much time does baby spend in each container?
Other relevant information
Covid-19 Questions
Have you or anyone in your household had any of the following symptoms in the last 21 days
Sore throat
Cough
Chills
Body aches for unknown reasons
Shortness of breath for unknown reasons
Loss of smell
Loss of taste
Fever at or greater than 100 degrees Fahrenheit
Have you or anyone in your household been tested for COVID-19?
Yes
No
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?
Yes
No
Have you or anyone in your household traveled in the U.S. in the past 21 days?
Yes
No
Have you or anyone in your household traveled on a cruise ship in the last 21 days?
Yes
No
Are you or anyone in your household a health care provider or emergency responder?
Yes
No
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?
Yes
No
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?
Yes
No
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?
Yes
No
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