Please check a box for either YES or NO for how these sentences apply to you and your baby
All options are required
Breastfeeding is easy and feels very natural with my baby
YES NO
Please check a box for either YES or NO for how these sentences apply to you and your baby
All options are required
Breastfeeding has been challenging
YES NO
I've had lactation assessments and advice, but we continue to struggle
YES NO
I have very sore and injured nipples
YES NO
When my baby comes off the breast, my nipples are appear compressed and beak-shaped
YES NO
My baby’s latch is better on one side compared to the other
YES NO
I seem to produce more milk on one side compared to the other
YES NO
My baby’s latch seems great, I have no discomfort and it feels perfect
YES NO
My baby frequently comes off the breast
YES NO
My baby has been diagnosed with a tongue-tie
YES NO
My baby appears uncomfortable and frustrated with breastfeeding
YES NO
BABY's DEMEANOR
All options are required
My baby is content and very relaxed emotionally and physically
YES NO
My baby seems tight and stiff, particularly in the arms and legs
YES NO
My baby frequently arches her back
YES NO
My baby dislikes diaper-changing
YES NO
My baby is fussy in the car-seat
YES NO
My baby does not tolerate tummy time
YES NO
My baby startles easily
YES NO
My baby seems gassy
YES NO
My baby spits up
YES NO
My baby does not sleep well
YES NO
Pregnancy and Birth
All options are required
While in utero, was your baby right-side laying?
YES NO
Did you have back labor?
YES NO
Did you have a C-section?
YES NO
Was your baby breech?
YES NO
Was vacuum extraction used?
YES NO
Were forceps used?
YES NO
Was your baby “pulled” out with your birth-provider’s hands?
YES NO
Was labor induced with the use of Pitocin?
YES NO
Did your baby have difficulty moving into the head down position?
YES NO
Baby’s physical appearance and posture
All options are required
My baby prefers to look to one side
YES NO
My baby’s head appears mis-shapen
YES NO
My baby has a flat area on the cranium
YES NO
My baby has facial asymmetries (significant or mild)
YES NO
My baby’s neck is tense
YES NO
My baby has a tight hip or hips
YES NO
My baby’s body is relaxed in all positions
YES NO
My baby’s chin appears slightly pulled back
YES NO
My baby’s head is tilted to one side
YES NO
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