Questionnaire for your support call with Kristen G

First Name*

Last Name*

Email*

Phone*

Country*

What do you hope to achieve on this call?

Your baby's name*

Your baby's age (actual, not adjusted if pre-term)*

Your baby's weight (IN POUNDS)*

Was your baby pre term?*

Yes

How Long Have You Suspect Reflux*

Less than a month

1-3 months

3-6 months

Over 6 months

When Was The Last Time You Felt Your Baby Was Well?*

Is This Your 1st Child With Reflux?*

Yes

Did Or Does Something Trigger Your Baby's Change In Health?*

List any special diets that you or your baby are on?*

Is there anything that makes your baby feel worse?*

Is there anything that makes your baby feel better?*

Does your baby have difficulty eating or gaining weight?

Yes

Any Additional Symptoms You'd Like To Explain*

Are feeding times enjoyable for you and your baby, or a source of anxiety/strain?

Yes it is a source of anxiety for me.

No I do not get anxious when feeding my baby

List of Any Medications Being Given (Include Dose/Times Per Day)*

How Long On Each Medication?*

Are there any drug allergies? (List any or reply no)*

Are there any other illnesses or conditions we should know about?*

Do you feel like your baby's symptoms are impacting your mental well being?*

Additional Comments

I am at least 16 years of age

Yes*

I agree to the COPPA Disclaimer

yes*

I want more info and promos on getting a happy healthy baby FAST.

yes*

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7533 Center View Ct
unit #4130
West Jordan Utah
84084

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Sun: CLOSED

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