Breastfeeding Health Review Report

Personal Info

Customer basic info

First Name

Last Name

FB Page Name

Date / Time

Phone no.

Address

Breastfeeding Experience

Newbies in Breastfeeding

This is my 2nd BF babies

This is my 3rd BF babies

This is my 4th BF babies

Current Breastfeeding Stage

0-1month

1-3months

3-6months

6months and above

Known Super Mom/Miss Mama from ?

FB ads

FB Group

Friends/ Family

Magazines Publication

Confinement Centre

Google

Others

Existing Issues

Tell us more about the issues you facing now

Existing Issues

Nipple pain while pumping

Areola being pulled into funnel

Nipple hit ends of funnel

Unemptied breast / hard breast after pumping

Frequently engorgement

Milk leaks during pumping, need to bend down prevent leaking

Need to pump more than 40 mins to clear the milk

Required hand massage OR cold/hot padding during pumping

Injuries

Nipple Cracks

Nipple skin peeled off

Sensitive nipples

Lump/sweling

Bleeding nipple/ areola

Swollen Areola

Strawberry milk

Breast Abscess

Looking for handsfree pump?

Yes

No

Breastpump Used (Breast Pump Brand & Model , Funnel Size Use. Level of Strength Use)

Do you latch your baby?

Non-latching

Only during first few days of birth

Only during the first few weeks

Every Interval of few days

Only during weekend

Daily 1-2 times

Daily 3-6 times

For Consultation Used

To be filled after tutorial

Nipple size (Before Pump)

Nipple size (After Pump)

Recommended funnel size

Additional Remarks

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