| Personal data |
Age: _______________ Nationality: _______________
Level of education: _____________ Profession: _______________
Week of lactation: _______________________
Previouspregnancies:
• Yes
• Ifyes, how many?_________________
• No
|
| Lifestyle |
Do you smoke?
• Yes
• Never smoked
• Former smoker
Do you drink alcohol beverages during lactation?
• No
• Yes, occasionally (less than threeglasses per week)
• Yes, quite frequently (3-14 glasses per week)
• Yes, usually (more than 14 glasses per week)
What foods do you consumemost frequently?
• Carbohydrates (pasta, bread, cakes): _____________
• Meat: _________________
• Vegetable: _____________
• Fish: __________________
• Fruit: __________________
|
Use of herbal products
during life |
Have you ever used herbal products?
• Yes
• No
|
Use of herbal products
during pregnancy/lactation |
Have you everusedherbal productsduring pregnancy/lactation?
• Yes
• No
(specify)_________________
If yes, which kind of product?
1. Homeopathic
2. Cosmetics
3. Medicinal herbal-based products
4. Herbal dietary supplements
5. Other food supplements (e.g. vitamins, minerals)
If possible, please, specifythe name of the product/s thathas been used?
1. ____________ 4. ______________
2. ____________ 5. ______________
3. ____________ 6. ______________
Why do you use herbal products (specify the reason)?
• Independent reasons of the lactation
__________________________________________
• Because of the lactation _______________________________________
• Both ___________________________________________
What is/was the frequency and the duration of your herbal treatment/s?
Please, specify: _____________________________________________ |
