Allergy Questionnaire

Please note that the completion of this form alone does not produce a client / consultant relationship between us.

This set of questions is adapted from questions in my colleague Maureen Minchin’s book Milk Matters, or her e-book Crying Babies and Food. See http://infantfeedingmatters.com/milk-matters-the-book/

Parent Allergy Questionnaire

Birthing / Lactating Parent's Full Name
First Last
Second Parent's Full Name
First Last
Contact email address
Enter Email Confirm Email
Any pregnancy abnormalities
Method of baby's birth
Did anyone smoke in your household when you were a child?
- parent 1 - yes
- parent 2 - yes
- parent 1 - no
- parent 2 - no
Parent 1: do you smoke?
- Yes
- No
Parent 2: do you smoke?
- Yes
- No
Parent 1: when did you stop smoking?
Do biological parents and their closest blood relatives, have any medical conditions, allergies, intolerances or immune disorder? For example hormonal or thyroid, IBS, diabetes, arthritis, allergies etc. Please disclose anything whether or not you believe it is related.
Does the baby / do the babies have any medical conditions?
What do both of you know about your births and how you were fed as a baby? (When you were born, was the birth stressful? C-section? Maternal illness?) (Ask, if possible.)*
Were either of you or your mothers given antibiotics early in your life?
Birth and subsequent weights and dates where appropriate for both parents, if known
Were both / either of you breastfed? How long for?
- Yes
- No
Were both / either of you exposed to formula in hospital? In your early days? Do you know what kind?
- Yes
- No
Did both / either of you receive formula in the first 4 months of life?*
- Yes
- No
Regularly formula-fed from ? weeks/months. Do you know what kind?
What were baby's parents' early solid foods? When were they introduced?*
What have your parents or other relative said about you (an easy/difficult baby) or your food habits when you were young? Did you cry a lot? Did you sleep well?
Your memories about food and drink as a child: What do you remember about liking or disliking foods as a child? ..... What about favourite foods as a child? ….. Did you get free school milk and if yes, did you enjoy it?
What do you both know about your health as children? list any that apply: • Gut problems: colic, reflux/vomiting, constipation, diarrhoea, control problems • Eczema, cradle cap, skin problems • Asthma, croup, bronchitis, lower respiratory problems • Hayfever, earaches, upper respiratory problems • Fevers, night sweats • Headaches, migraine, joint pains • Bedwetting, urinary tract infections • Learning difficulties • Sleep difficulties, snoring, night-waking, nightmares, night terrors • Emotional mood swings, concentration and behaviour problems • Do you experience these problems now? ….. Which? ..... Occasionally or often? ….. Others?
What if any medications do you use fairly frequently? (antihistamines, antacids, paracetamol, aspirin, ibuprofen, skin creams, nutrient supplements etc) ..... Why?
How many and what caffeine-containing drinks would you have daily? ..... Any ‘sugar-free’ products? Protein supplements? If so, what?
Are you aware of immune problems (diabetes, psoriasis, migraine, asthma etc) in: • yourself • parents, siblings • your child’s other parent • their family • older family members
If you have siblings and/or other children, what ages are they now?
Were they ‘easy’ babies and toddlers?
Make a note of any reactions you have observed to chemicals, pollens, dust, smoke, fragrances, cosmetics or environmental annoyances of any kind. They may also be relevant.
Pregnancy - Did you have any problems conceiving this/any child?
How much cows’ milk in any form (cheese, yoghurt, ice cream, milk, custard, butter – and all ingredients etc.) do/ did you have daily? None - Occasional - Daily - Lots On a scale of 1–10 how much did you like plain milk during pregnancy?
What three foods did you like most and least when pregnant?
When pregnant, did your food likes and dislikes change? If so, how?
Did your eating habits change during pregnancy? If so, how? Any food binges? Aversions?
What were your pregnancy weight gains?
What pregnancy-related symptoms have you been/were you aware of?
Have you ever noticed any connection between food aversion / cravings, allergy symptoms and stages of your menstrual cycle?
Any other comments?
STANDARD DECLARATION:*
The above information is true to the best of my knowledge. I understand that any information, support or expertise offered is done so on the basis of information I disclose above or in person, and so in limiting the information I am limiting the usefulness of any advice which I may receive.

I hereby agree to reimburse Shel Banks IBCLC Lactation Consultant at the rate mutually agreed, either before or during any agreed consultation.

I agree to Shel Banks sharing the outcome of our discussion with my child's healthcare providers where this is relevant, either via the Child Health Record (Red Book) or by contacting the healthcare professional direct. I agree to Shel consulting with colleagues on my child's feeding history, using anonymous information, so she can provide better care for us. I understand that all personal or identifiable information shared here is confidential except where there is a safeguarding risk to a child or a vulnerable adult, or as specified above..
- I agree
Untitled
Email
This field is for validation purposes and should be left unchanged.

Save and Continue Later