www.tucsonbiodentistry.com - Frenectomy Health History Form

  • Frenectomy Health History Form

  • Date of Visit
     - -

  • Frenotomy and Frenectomy

  • Medical History

  • Received Vitamin K injections?*
  • Was your infant premature?*
  • Does your infant have heart disease?*
  • Has your infant had any surgery?*
  • Has your baby had prior surgery to correct tongue / lip tie?*

  • Select "Yes" or "No" all that apply

  • Baby’s Symptoms

  • Poor latch*
  • Falls asleep while attempting to latch*
  • Colic*
  • Reflux*
  • Poor weight gain*
  • Gumming or chewing nipple while nursing*
  • Unable to hold a pacifier in his/ her mouth*
  • Short sleep episodes requiring feeding every 2-3 hours*

  • Mother’s Symptoms

  • Creased, flattened or blanched nipples after nursing*
  • Cracked, bruised or blistered nipples*
  • Bleeding nipples*
  • Severe pain when infant attempts to latch*
  • Poor or incomplete breast drainage*
  • Infected nipples or breasts*
  • Plugged ducts*
  • Mastitis or nipple thrush*
  • Family history of Tongue Tie?*
  • Family history of Lip Tie?*
  • Has your baby had any of the following?
  • Date*
     - -
  • Should be Empty: