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Family Information
Full Name:
*
Telephone Number:
*
Email Address:
*
Baby's name:
Gender:
*
Menino
Menina
Surpresa
Birth Date:
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Type of delivery?
*
Natural Birth
Scheduled Cesarean
Unplanned Cesarean
Induction
How many weeks were you when the baby was born?
Does your baby have reflux or any type of health issue?
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Yes
No
Are both parents working away from home? Who stays with the baby?
Do you have more kids? How many and what are their ages?
Are you breastfeeding or formula feeding?
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Breastfeeding
Formula
Where does the baby sleep?
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Parents bed
Bassinet next to parents' bed
Crib in another room
Does your baby nap during the day?
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Yes
No
How many times and for How long?
*
What time does the baby go to bed at night?
*
What time does the baby wake up in the morning?
*
Why are you looking for this consultation and what are you trying to accomplish? Please give us details.
*
Have you talked to you pediatrician about the issue and what was the doctor's response on the matter?
*
Anything else you would like to add?