New Patient Form

Are you a new patient? Save yourself time in the office by completing and submitting the new patient form before your arrival.

Or download the form, fill it out, and bring it with you to your appointment.

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Thank you for visiting our office! We want your visit to be pleasant and comfortable. Please help us by completing this form entirely.

Phone

Last Name

First Name

Nickname

Street

City

State

Zip

Tongue / Lip Tie Questionnaire

Phone

Patient's DOB

Patient's Name

Parent's Name

Home Address

Reason for Visit

Pediatrician's Name

Are you currently working with a lactation consultant?

If so, who?

Do you work with them at home or a hospital setting?

Is your child currently being seen by anyone such as chiropractors, craniosacral therapists, PT, OT, etc.?

If yes, what type & with whom?

Birth Weight

Most Current Weight

Date of Most Current Weight

Allergies of any type whether food product or medicine?

Please list all medications baby is taking:

Was your child premature?

If yes, what was the gestational age at birth?

Does your child have any medical conditions of any kind?

If yes, please list:

Has your child had any surgeries including previous lip or tongue revisions?

If yes, please list:

PREGNANCY/LABOR/BREASTFEEDING QUESTIONS

Any stressors during labor?

If yes, please explain:

Was there difficulty with your baby properly latching at birth?

If yes, please explain:

Are you exclusively breastfeeding or supplementing (pumped breast milk or formula)?

Are you using a nipple shield?

How would you rate your milk supply?

Is your child within breastfeeding age?

How would you rate your baby's latch? (select one)

5 - No issues

4 - Minor issues

3 - Major issues

2 - Breast damage

1 - Mostly using bottle

0 - No latch

Does your little one fall asleep nursing?

How long do feedings last?

Does your little one frequently fall off the breast/lose his latch while nursing?

Does your little one's top lip flange up or does it curl under during breastfeeding?

Does milk or formula leak out of your little one's mouth while feeding?

Does your little one exhibit reflux?

Is your little one frequently gassy?

Has your little one's weight gain been ON the curve or BELOW it?

If working with a lactation consultant, have they done pre and post feeding weight checks?

If they have, what has been the transfer rate?

Does your little one require feedings sooner than every 2-3 hours?

Do you notice a clicking noise while your little one is feeding whether breast or bottle?

How much discomfort do you experience while breastfeeding? (select one)

Not applicable

0 - None

1 - Very low

2 - Not much

3 - Moderately Painful

4 - OMG

5 - Unbearable

Are your nipples lipstick-shaped following feedings?

Have you experienced any cracking, bleeding or bruising to your nipples after nursing?

Is there severe pain when your little one attempts latching?

If so, which side or both?

Are you experiencing incomplete breast drainage?

Have you had or do you currently have mastitis?

Have you or your little one had thrush?

Please briefly describe your goals with feeding or breastfeeding:

Who referred you to our office today?

Forms

New Patient Form