Infant Frenectomy Intake Form

Infant Intake Form for Frenectomy
Patients Name
Patient's DOB

MonthDayYear
Date
Patients Age
Sex

FemaleMale
Pediatrician
Telephone #
Are you currently working with a lactation consultant?

YesNo
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.)

YesNo
Is your child currently being seen for other services? (chiropractic care, physical therapy, occupational therapy,

craniosacral therapy, speech therapy, feeding therapy, etc YesNo
If yes, what type
Why by whom
When / total of visits
Do you have any concerns with your child’s gross motor development? (rolling, sitting, crawling, etc.)

YesNo
If yes, which & why
Does your child have a preference for turning or tilting his/her head? (in car seat, while sleeping, etc.)

YesNo
Does your child have a preference for turning or tilting his/her head? (in car seat, while sleeping, etc YesNo
If yes, which?
Are you concerned with your baby's head shape?

YesNo
Is this your first child?

YesNo
Is there a family history of tongue/lip tie?

YesNo
Did your child receive Vitamin K injections?

YesNo
Has your child had prior surgery to correct a tongue or lip tie?

YesNo
If yes, what types and where?
Pregnancy / Labor History

NormalHigh risk
Birth Location
Was your child premature?

YesNo
If yes, gestational age at birth
Were there any additional stressors with labor?

YesNo
Please select all that apply:

Vaginal birthLong LaborUnplanned C-SectionPlanned C-SectionExcessive PushingTrauma From Vacuum or ForcepsBreech
If other, please explain
Difficulty with latch after birth

YesNo
Mode of Feeding
Please describe your current modes of feeding
Are you currently breastfeeding?

YesNo
If yes, please select

Exclusively breastfeedingMix of breast / bottle feeding
How would you rate your milk supply?

OversupplyGoodFairPoor
Do you have a history of breast surgery?

YesNo
Are you currently using a nipple shield

YesNo
Are you using an SNS?

YesNo
Is this your first time breastfeeding?

YesNoN/A
Other breastfed children?

YesNo
How long?
Are you supplementing with pumped breast milk?

YesNo
How many bottles/ounces per day
Are you supplementing with formula?

YesNo
How many bottles/ounces per day
Type of formula
Does your baby use a pacifier?

YesNo
Baby's Symptoms
Does your baby CONSISTENTLY fall asleep while attempting to nurse?

YesNo
Does your baby CONSISTENTLY slide off breast when latching/feeding?

YesNoN/A
Does their upper lip CONSISTENTLY curl inward (does not flip out/flare) when latched?

YesNo
Does your baby CONSISTENTLY have their mouth open at rest?

YesNo
Does milk or formula leak/spill out of mouth while feeding at breast or bottle?

YesNo
Does your baby CONSISTENTLY experience colic symptoms?

YesNo
Does your baby CONSISTENTLY become visibly frustrated at the breast/bottle?

YesNo
Does your baby CONSISTENTLY exhibit reflux symptoms?

YesNo
Is your baby CONSISTENTLY extremely gassy?

YesNo
Does your baby CONSISTENTLY snore during sleep?

YesNo
Does your baby CONSTENTLY exhibit noisy/congested breathing?

YesNo
Has your pediatrician noted slow or poor weight gain?

YesNo
Have you done any pre & post feeding weight checks?

YesNo
If yes, what was the transfer rate:
Ounces
per how many minutes
Does your baby CONSTENTLY display gumming or chewing of your nipple whiling nursing?

YesNo
Is there a CONSISTENT “clicking noise” while feeding?

YesNo
Does your baby seem CONSISTENTLY dissatisfied after feeding sessions?

YesNo
If yes, please explain
What is the average length of feeding time in minutes?

Less than 15 minutes15-30 Minutes30-45 Minutes45-60 Minutes60+ Minutes
Mother's Symptoms (if breast feeding)
Please rate your level of discomfort while feeding:

NoneVery LowLowMediumHighVery High
Are your nipples becoming creased/flattened/lipstick-shaped/blanched white after nursing?

YesNo
If yes, please select:

Right SideLeft SideBoth
Are your nipples becoming cracked, bruised, or blistered after nursing?

YesNo
If yes, please select:

Right SideLeft SideBoth
Are your nipples bleeding?

YesNo
If yes, please select:

Right SideLeft SideBoth
Is there any severe pain when your baby attempts to latch?

YesNo
If yes, please select:

Right SideLeft SideBoth
If yes, please select:

Pain subsides after initial latchPain persists throughout feedingPain is felt in-between feeds
Are you experiencing poor or incomplete breast drainage?

YesNo
Do you have a history of, or currently have, mastitis?

YesNo
Do you have a history of, or currently have, nipple/baby oral thruth?

YesNo
In a sentence or two, please share your current feeding concerns

0/100
In a sentence or two, please share your feeding goals

0/100
Parent Name
Date

MonthDayYear
Date
Parent Signature

Clear
Should be Empty: