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Home › Prenatal Breastfeeding Questionnaire

Prenatal Breastfeeding Questionnaire

Prenatal Breastfeeding Questionnaire

Name

Date

Due Date

Address

Phone

Email Address

What are your breastfeeding concerns/questions?

What are your breastfeeding goals?

What is your breastfeeding experience?

Have you had any of the following?

Breast Augmentation

Breast Reduction

Other Breast Surgery

Nipple Piercing

Have you had any of the following related to pregnancy?

Gestational Diabetes

Hypertension

Multiple Gestation

Infertility

Unusual Bleeding

Pre-Term Labor

Describe any breast changes you have had during pregnancy

Do you have

PCOS

Diabetes

Insulin Resistance

Eating Disorder

Do you have any other health or pregnancy concerns?

If you are human, leave this field blank.

Located in Central lower Michigan

For more information, call (517) 285-7819 or email feedthebabyllc@protonmail.com
Laura Spitzfaden

International Board Certified Lactation Consultant providing in-home visits for breastfeeding support in Lansing, Michigan and surrounding communities

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None of the information on this site is intended to replace medical advice. Please consult your health care provider for medical advice.

Original artwork Copyright ⓒ 2012 Cameron Spitzfaden

None of the information on this site is intended to replace medical advice. Please consult your health care provider for medical advice.

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