Frenotomy/Frenectomy Intake Form If you are a human and are seeing this field, please leave it blank. GENERAL INFORMATION Patient Name Referring Physician Date of Birth Date of Visit Pharmacy Name/Phone/Address Lactation Consultant Medication Allergies Current Medications (include over-the-counter/herbal/vitamins) PAST MEDICAL HISTORY Birth Weight (lb/oz) Present Weight (lb/oz) Please Check All That Apply: Have you received Vitamin K injections? Was your infant premature? * If yes, give gestation age in weeks Does your infant have any heart disease? * If yes, explain Has your infant had any surgery? * If yes, explain Has patient had prior surgery to correct the tongue or lip tie? * If yes, when/by whom? BABY's SYMPTOMS (CHECK ALL THAT APPLY) Poor latch Falls asleep while attempting to nurse Slides off the nipple when attempting to latch Colic symptoms Reflux symptoms Poor weight gain Gumming or chewing of your nipple when nursing Unable to hold pacifier in his/her mouth Short sleep episodes requiring feeding every 2-3 hours MOTHER'S SYMPTOMS (CHECK ALL THAT APPLY) Creased, flattened, or blanched nipples after nursing Cracked, bruised, or blistered nipples Bleeding nipples Severe pain when your infant attempts to latch Poor or incomplete breast drainage Infected nipples or breasts Plugged ducts Mastitis or nipple thrush HAS YOUR BABY HAD ANY OF THE FOLLOWING? Weight loss/gain Nasal obstruction Swallowing issues Cyanosis (turning blue) Breathing issues Reflux/vomiting/spitting up Bleeding problems FAMILY HISTORY Do you have a family history of tongue tie? Do you have a family history of lip tie?