Breast Feeding Survey
1
. 1. With your youngest child, did you breast feed?
1. With your youngest child, did you breast feed?
Yes
No
2
. 2. If so, why did you breast feed? If not, why? If you did not breast feed, end questionnaire here.
2. If so, why did you breast feed? If not, why? If you did not breast feed, end questionnaire here.
3
. 3. While breast feeding, were you focused on/concerned with what you were eating? Please explain.
3. While breast feeding, were you focused on/concerned with what you were eating? Please explain.
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. 4. How long did you breast feed? Did your diet ever drastically change during this time? Please explain.
4. How long did you breast feed? Did your diet ever drastically change during this time? Please explain.
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. 5. Can you provide me with a typical day’s type of food? What do you eat for breakfast/lunch/dinner?
5. Can you provide me with a typical day’s type of food? What do you eat for breakfast/lunch/dinner?
6
. 6. Please indicate if you consumed the following while breast feeding:
6. Please indicate if you consumed the following while breast feeding:
caffeine
antibiotics
multivitamins
prebiotics/probiotics
dairy
dietary supplements
meat
fruit
vegetables
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. 7. Do you think what you eat impacts the milk you provide for your child? Please explain.
7. Do you think what you eat impacts the milk you provide for your child? Please explain.
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. 8. Demographic questions- Please answer as you feel comfortable
a) In what age category do you fall?
8. Demographic questions- Please answer as you feel comfortable a) In what age category do you fall?
1) 16-20 years
2) 20-25 years
3) 25-30 years
4) 30-35 years
5) 35-40 years
6) 40-45 years
7) 45-50 years
8) 50-55 years
9) 55 or older
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. b) What is your level of education?
b) What is your level of education?
10
. c) What ethnicity are you?
c) What ethnicity are you?
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