Breastfeeding Survey Questionnaire

A breastfeeding survey questionnaire puts across important questions to breastfeeding women or pregnant women. This type of questionnaire helps the medical professionals to understand if the mother is breastfeeding the child properly and taking the necessary precautions.

Breastfeeding Survey Questionnaire:

Name of the Respondent: __________________________________

Work Phone: ____________________  Email id:______________________

Name of the child:_________________  Age: _______________ (months)

Q1. What type of delivery did you undergo?

a)   Unassisted vaginal

b)   Vaginal with forceps

c)   Vaginal with vontuse

d)   Vaginal with epidural/spinal block

e)   Elective caesarean with general anesthetic

f)    Elective caesarean with epidural/spinal block

g)   Emergency caesarean with general anesthetic

h)   Emergency caesarean with epidural/spinal block

Q2. Have you been breastfeeding your child from the first day itself?

a)   Yes

b)   No

Q3. How long do you plan to continue breastfeeding?

a)   1 month

b)   2 months

c)   3 months

d)   4 months

e)   5 months

f)    6 months

Q4. Are you using a branded baby formula instead of breastfeeding your child?

a)   Yes

b)   No

Q5. Which of the following lifestyle habits do you pursue during the breastfeeding period?

a)   High fatty foods

b)   High cholesterol food

c)   Junk food

d)   Alcohol

e)   Smoking

f)    Sleeping pills

Q6.  Are you breastfeeding 8 to 12 times daily? If your answer is no then please specify

a)   Yes

b)   No

c)   Reason:__________________________

Q7. Does your breastfeeding sessions last 20 to 45 minutes?

a)   Yes

b)   No

Q8. Which of the following issues have you faced in the recent past?

a)   Your milk quantity has not increased

b)   You suffer from sore nipples

c)   Your baby is not feeding as required

d)   Your baby is not suckling well

e)   Your baby seems to be hungry after each breastfeeding session

f)    Breastfeeding challenges like twins

g)   Baby sleeping on the breast

h)   Uncomfortable breastfeeding



Medical Surveys

Category: Survey Questionnaire

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