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Intake Form

Fill the form below before your tongue tie consultation or print the form by clicking the button below

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Intake Form

Infant's Name

First Last

Email

Birth Date

MM slash DD slash YYYY

Today's Date

MM slash DD slash YYYY

Gender

Female

Male

Birth Weight

Present Weight

Birth Location

Birth

Vaginal

C-section

Any Complications?

Are You Currently Breastfeeding?

Yes

No

If no, how long since you stopped?

Medical History

Did your baby receive a Vitamin K shot?

Yes

No

Was your infant premature?

Yes

No

Does your infant have any heart disease?

Yes

No

Has your infant experienced any of the following?

Yes

No

Has your infant experienced any of the following?

Shallow latch at breast or bottle

Falling asleep during feeding

Slides or pops of the nipple

Gagging choking or coughing during feed

Poor or slow weight gain

Hiccups often

Lots of hiccups in utero

Gumming or chewing the nipple

Pacifier falls out easily

Snoring, noisy breathing, or mouth breathing

Short sleeping or waking often

Baby moves a lot in sleep/restless sleep

Baby seems always hungry and not full

Lip curls under when nursing or taking a bottle

Clicking or smacking noises when eating

Sucking blisters or callouses on lip

Colic symptoms/ baby cries a lot

Reflux symptoms

Spits up often

Gassy/fussy often

Milk leaks out of mouth when nursing/bottle

Nose sounds congested often

Baby is frustrated at the breast or bottle

How long does it take baby to eat?

How often does baby eat?

Is your infant taking any medication? If yes, what?

Has your infant had a prior surgery to correct the tongue or lip tie? If yes, where, when, and by whom?

Does mom have any of the following symptoms now or in the past?

Creased, flattened , or blanched nipples

Lipstick shaped nipples

Blistered or cut nipples

Bleeding nipples

Poor or incomplete breast drainage

Decreasing milk supply

Plugged ducts/ engorgement/mastitis

Nipple thrush

Using nipple shield

Baby prefers one side over the other

Feeling hopelessness/depression

Pain on a scale of 1-10 when latching

Pain on a scale of 1-10 when nursing

Primary care provider

Chiropractor/PT/CST

Lactation consultant

Other therapist/ provider

How far away do you live?

Who referred you to us?

Δ

woodlands tongue tie center 01

Inside Alden Bridge Pediatric Dentistry.

3759 FM 1488 Suite 125 The Woodlands, TX 77384
Ph: 832 521-9024
kimthekidsdentist@gmail.com

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