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Home
Office
Dr. Crespi
Dr. Leff
Office Tour
Dental Insurance
Our Philosophy
Staff
Orthodontics
Blog
The Sunrise Difference
Our Mission
Dentistry
Laser Dentistry
Technology
Board Certified in Pediatrics
Emergency Care
Partners
Patients
Payment
Your Child's Visit
Treatment
Patient Handouts
Sunrise Advantage Plan
Frenulectomies
Forms
Patient Forms
Referral Form
Contact
Infant Frenectomy Assessment
Parents Name
*
First Name
Last Name
Date
MM
DD
YYYY
Patient Name
*
First Name
Last Name
DOB
MM
DD
YYYY
How did you hear about our office?
Did your infant recieve vitamin K at birth
Yes
No
Has your infant had any surgeries?
Yes
No
Does your infant have any heart disease?
Yes
No
Family history of bleeding disorder?
Yes
No
Was your child premature?
Yes
No
If yes, number of weeks?
Was your pregnancy high risk?
Yes
No
Type of Delivery: (Check all that apply)
Home
Hospital
Vaginal
C-section
Any other stressors with labor?
Long Labor
Trauma from Forceps
Breech
Unplanned C-section
Is your child taking any medications? (Reflux, thrush, etc.)
Yes
No
If yes, please list:
Food Allergies:
Medication Allergies:
Does your infant have any other health concerns?
Pediatrician's Name:
Birth Weight:
Current Weight:
Are you currently working with a lactation consultant?
Yes
No
If yes, who?
Is your infant being seen for bodywork? (Chiropractor, physical therapy, osteopath, myofunctional therapy, other?)
Yes
No
If yes, who?
Is this your first child?
Yes
No
Family History of lip/tongue tie?
*
Yes
No
Check all that apply:
Breastfeeding
Pumping
Formula
Nipple Shield
SBS Device
Is this your first time breast-feeding?
Yes
No
Other breastfed children? How long did you breastfeed them for?
Are you supplementing with pumped breast milk?
Yes
No
If yes, how many oz/bottles per day?
Are you supplementing with formula?
Yes
No
If yes, how many oz/bottles per day?
How would you rate your milk supply?
Oversupply
Good
Fair
Poor
Have you done pre/post feeding weight checks?
Yes
No
If yes, what is transfer rate? (oz/min)
MOTHER'S SYMPTOMS:
Creased, dry, cracked, or bleeding nipples
Painful latch
Poor or incomplete breast draining
Clogged ducts/ mastitis
Thrush
Oversupply of breastmilk
Heavy let down
Undersupply of breastmilk
Depression
Average length of feeding time? (Minutes)
Less than 15
15-30
30-45
45-60
60+
Infant's Symptoms
Difficulty of achieving a good latch
Slow nursing, often falls asleep
Comes unlatched often
Reflux
Poor weight gain
Frequent feeding 9every 1-2 hours)
Waking up congested in morning
Milk leaking out of mouth during nursing
Gas of frequently swallowing air
Upper lip tucked under when latched
Colic
Mouth open at rest
Chin quivers
Frequent Hiccups
Thank you!
