www.tucsonbiodentistry.com - Frenectomy Health History Form

Frenectomy Health History Form
Patient Name*

First NameLast Name
Mom's Name
Dad's Name
Date of Birth*

MonthDayYear
Referring Provider
Date of Visit

MonthDayYear
Date
Frenotomy and Frenectomy
Lactation Consultant
Medication Allergies
Current Medications (include over-the-counter, herbal, vitamins)
Medical History
Birth Weight
Current Weight
Received Vitamin K injections?*

YesNo
Was your infant premature?*

YesNo
Does your infant have heart disease?*

YesNo
If "Yes" Please Explain?*
Has your infant had any surgery?*

YesNo
If "Yes" Please Explain?*
Has your baby had prior surgery to correct tongue / lip tie?*

YesNo
If yes, when / by whom?*
Select "Yes" or "No" all that apply
Baby’s Symptoms
Poor latch*

YesNo
Falls asleep while attempting to latch*

YesNo
Colic*

YesNo
Reflux*

YesNo
Poor weight gain*

YesNo
Gumming or chewing nipple while nursing*

YesNo
Unable to hold a pacifier in his/ her mouth*

YesNo
Short sleep episodes requiring feeding every 2-3 hours*

YesNo
Mother’s Symptoms
Creased, flattened or blanched nipples after nursing*

YesNo
Cracked, bruised or blistered nipples*

YesNo
Bleeding nipples*

YesNo
Severe pain when infant attempts to latch*

YesNo
Poor or incomplete breast drainage*

YesNo
Infected nipples or breasts*

YesNo
Plugged ducts*

YesNo
Mastitis or nipple thrush*

YesNo
Family history of Tongue Tie?*

YesNo
Family history of Lip Tie?*

YesNo
Has your baby had any of the following?

Weight loss/ gain?Nasal obstructionSwallowing issuesCyanosis/ turning blueBreathing issuesReflux/ vomiting/ spitting upBleeding problems
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Frenectomy Health History Form

Frenotomy and Frenectomy

Medical History

Select "Yes" or "No" all that apply

Baby’s Symptoms

Mother’s Symptoms