Thank You for Completing the Questionnaire Prior to Your Tongue-Tie and Breastfeeding Consultation! Today's Date Patient's Name Patient's Date of Birth Parent's Name Email Phone Birth Weight Current Weight Lactation Consultant and Date Last Seen. How are you currently feeding your child? Formula Breastmilk Both Please check one: Hospital Birth Home Birth Please check one: Vaginal birth C-section Please check one: Vacuum Forcep Assisted Neither Has your child received Vitamin K Injections? Yes No Unsure At what week was your baby born? Any medical problems/concerns for your child? Has your child had any surgeries? If Yes, please specify. Has your child received a tongue/lip tie procedure in the past? If Yes, by when? and by who? Please check off your child's symptoms My baby's latch is weak, poor, and/or painful Falls asleep while attempting to nurse/bottle feed Slides off nipple, breast/bottle while attempting to latch Colic, reflux, gassy symptoms or spitting up Weight Gain/loss Gumming or chewing of nipple-breast/bottle Clicking noise or loss of suction while breast or bottle fed Breast milk/formula leakage from mouth, nose, or both Please check off mom's symptoms Flattened, cracked, bleeding, blistered nipples Severe pain when attempting to latch Plugged ducts, mastitis, nipple thrush Family history of tongue/lip tie Mom, is one side more difficult to nurse? If so, which side? How long does it take you baby to feed? Do your breasts still feel full after nursing? Yes No I am currently not breastfeeding Would you like to share anything else with us? Send
