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English (US)
Prenatal Infant Feeding Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Daytime Phone Number
Please enter a valid phone number.
Do you consent to receive text messages to the number you've provided?
Yes
No
Email Address
example@example.com
Estimated Due Date
-
Month
-
Day
Year
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On a scale of 1 to 10, how likely are you to breastfeed?
1 being very unlikely, 10 most likely
How does the baby's father want you to feed the baby?
Breastfeed
Formula
Unsure
How were you fed as an infant?
Breastfed
Formula
Both
Unsure
If you have other children, how did you feed them?
Breastfed
Formula
Both
Have you ever known anyone who breastfed?
Yes
No
Who did you know that breastfed?
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It's easier to breastfeed than to formula feed.
True
False
Formula is as good as breast milk for your baby.
True
False
Breastfeeding is painful.
True
False
Most women have low milk supply and have to supplement with formula.
True
False
Breastfeeding in public would be embarrassing.
True
False
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If you plan to breastfeed, how long will you breastfeed?
Are you currently working or in school?
Yes
No
Do you plan to return to work or school after delivery?
Yes
No
If yes, when?
If yes, what days and hours will you work or go to school?
Do you have a breast pump?
Yes
No
What kind of breast pump do you have?
Would you be able to use a breast pump at work/school?
Yes
No
Do you smoke?
Yes
No
If yes, how much per day?
Are you interested in participating in any WIC breastfeeding programs? (Please check all that interest you.)
Breastfeeding Encouragement Group
Breastfeeding Buddy Program
Breastfeeding Class
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