Infant Intake Form for Frenectomy
Patient's Name
Patient's DOB
-
Month
-
Day
Year
Date
Patient's Age
Sex
Male
Female
Pediatrician
Pediatrician Telephone #
Format: (000) 000-0000.
Are you currently working with a lactation consultant?
Yes
No
If yes, who and when?
Is your child currently being seen for other services? (chiropractic care, physical therapy, occupational therapy, craniosacral therapy, speech therapy, feeding therapy, etc
Yes
No
If yes, what type?
Why and by whom?
When/total number of visits?
Do you have any concerns with your child's gross motor development? (rolling, sitting, crawling, etc)
Yes
No
If yes, which and why?
Does your child have a preference for turning or tilting his/her head? (in car seat, while sleeping, etc)
Yes
No
If yes, which?
Are you concerned with your baby's head shape?
Yes
No
Is this your first child?
Yes
No
Is there a family history of tongue/lip tie?
Yes
No
Did your child receive Vitamin K injections?
Yes
No
Has your child had prior surgery to correct a tongue or lip tie?
Yes
No
If yes, what types and where?
Pregnancy / Labor History
Normal
High Risk
Birth Location
Was your child premature?
Yes
No
If yes, gestational age at birth?
Were there any additional stressors with labor?
Yes
No
Please select all that apply:
Vaginal birth
Long Labor
Unplanned C-Section
Planned C-Section
Excessive Pushing
Trauma from vacuum or forceps
Breech
Other (please explain)
Difficulty with latch after birth?
Yes
No
Modes of Feeding
Please describe your current modes of feeding
Are you currently breastfeeding?
Yes
No
If yes, please select:
Exclusively breastfeeding
Mix of breast / bottle feeding
How would you rate your milk supply?
Oversupply
Good
Fair
Poor
Do you have a history of breast surgery?
Yes
No
Are you currently using a nipple shield?
Yes
No
Are you using an SNS?
Yes
No
Is this your first time breastfeeding?
Yes
No
N/A
Other breastfed children?
Yes
No
How long?
Are you supplementing with pumped breast milk?
Yes
No
How many bottle/ounces per day?
Are you supplementing with formula?
Yes
No
How many bottles/ounces per day?
Type of formula
Does your baby use a pacifier?
Yes
No
Baby's Symptoms
Does your baby CONSISTENTLY fall asleep while attempting to nurse?
Yes
No
Does your baby CONSISTENTLY slide off breast when latching/feeding?
Yes
No
N/A
Does their upper lip CONSISTENTLY curl inward (does not flip out/flare) when latched?
Yes
No
Does your baby CONSISTENTLY have their mouth open at rest?
Yes
No
Does milk or formula leak/spill out of mouth while feeding at breast or bottle?
Yes
No
Does your baby CONSISTENTLY experience colic symptoms?
Yes
No
Does your baby CONSISTENTLY become visibly frustrated at the breast/bottle?
Yes
No
Does your baby CONSISTENTLY exhibit reflux symptoms?
Yes
No
Is your baby CONSISTENTLY extremely gassy?
Yes
No
Does your baby CONSISTENTLY snore during sleep?
Yes
No
Does your baby CONSTENTLY exhibit noisy/congested breathing?
Yes
No
Has your pediatrician noted slow or poor weight gain?
Yes
No
Have you done any pre & post feeding weight checks?
Yes
No
If yes, what was the transfer rate:
ounces
ounces per
minutes
minutes.
Does your baby CONSTENTLY display gumming or chewing of your nipple whiling nursing?
Yes
No
Is there a CONSISTENT “clicking noise” while feeding?
Yes
No
Does your baby seem CONSISTENTLY dissatisfied after feeding sessions?
Yes
No
If yes, please explain
What is the average length of feeding time in minutes?
Less than 15 minutes
15 - 30
30 - 45
45 - 60
60+ minutes
Mother's Symptoms (if breastfeeding)
Please rate your level of discomfort while feeding:
None
Very Low
Low
Medium
High
Very High
Are your nipples becoming creased/flattened/lipstick-shaped/blanched white after nursing?
Yes
No
If yes, please select
Right Side
Left Side
Both
Are your nipples becoming cracked, bruised, or blistered after nursing?
Yes
No
If yes, please select
Right Side
Left Side
Both
Are your nipples bleeding?
Yes
No
If yes, please select
Right Side
Left Side
Both
Is there any severe pain when your baby attempts to latch?
Yes
No
If yes, please select
Right Side
Left Side
Both
If yes, please select
Pain subsides after initial latch
Pain persists throughout feeding
Pain is felt in-between feeds
Are you experiencing poor or incomplete breast drainage?
Yes
No
Do you have a history of, or currently have, mastitis?
Yes
No
Do you have a history of, or currently have, nipple/baby oral thrush?
Yes
No
In a sentence or two, please share your current feeding concerns:
In a sentence or two, please share your feeding goals:
Parent Name
Parent Signature
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