northstarfamilydental.com - Mother Infant Assessment

Mother Infant Assessment

Infants – Less than one year old
Patient’s Name
Birthday*

MonthDayYear
Today’s Date

MonthDayYear
Gender

MaleFemale
Please use this form if your child is Infant
Medical Problems

Heart diseaseBleeding disordersOther
Birth Weight
Present Weight
Birth Hospital
Vaginal birth
C-Section Birth
Any birth complications?
Are you presently breastfeeding?

YesNo
If no, how long since you stopped breastfeeding?
Medical History:
Infants are usually given vitamin K at birth. Did your child receive the vitamin K shot?

YesNo
Was your infant premature?

YesNo
If yes, how many weeks?
Does your infant have any heart disease?

YesNo
Has your infant had any surgery?

YesNo
Has your infant experienced any of the following? Please check or elaborate as needed.
Shallow latch at breast or bottleGumming or chewing your nipple when nursingFalls asleep while eatingPacifier falls out easilySlides or pops on and off the nippleMilk dribbles out of mouth when nursing/bottleColic symptoms / Cries a lotShort sleeping requiring feedings every1-2hrsReflux symptomsSnoring, noisy breathing or mouthbreathingClicking or smacking noises when eatingFeels like a full-time job just to feed babySpits up often. Amount/ FrequencyNose congested oftenGagging, choking, coughing when eatingBaby is frustrated at the breast or bottleGassy (toots a lot) / Fussy oftenLip curls under when nursing/with bottlePoor weight gainHiccups often
Spits up often. Amount/ Frequency
How long does baby take to eat?
How often does baby eat?
Is your infant taking any medications?

RefluxThrush
Name of medication
Has your infant had a prior surgery to correct the tongue or lip tie?

YesNo
If yes, when, where, and by whom?
Do you have any of the following signs or symptoms? Please check and elaborate as needed

Creased, flattened or blanched nipplesPoor or incomplete breast drainageLipstick shaped nipplesInfected nipples or breastsBlistered or cut nipplesPlugged ducts / engorgement / mastitisBleeding nipplesNipple thrushPain when first latchingUsing a nipple shieldPain during nursingBaby prefers one side over other
Pain on a scale of 1-10 when first latching
Pain (1-10) during nursing
Right / Left?
Pediatrician
Phone Number
Please enter a valid phone number.
Lactation Consultant
Phone Number
Please enter a valid phone number.
Who referred you to us?
Should be Empty:

Mother Infant Assessment

Medical History:

Has your infant experienced any of the following? Please check or elaborate as needed.