SD - Infant Feeding Intake Form
INFANT FEEDING INTAKE FORM
Thank you for taking the time to complete the infant feeding intake form. The information in this form will be used at your consultation with Dr. Liu to determine if there is a physical oral problem affecting your ability to breastfeed or bottle feed your baby.
Please enter the personal details of your INFANT below.
Unspecified/Prefer Not To Answer
Date of Birth
Postal /Zip Code
Are you available for short notice appointments? (Check if available)
How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.
Emergency Contact First Name
Emergency Contact Last Name
Emergency Phone #
PARENT CONTACT INFORMATION
Best time to contact you:
INFANT BIRTH INFORMATION
Number of weeks:
Name of Midwifery Clinic:
Name of Hospital or Facility/Clinic where baby was born:
MOTHER'S NURSING HISTORY
How is your baby currently feeding? Check all that apply:
Please check the appropriate boxes as the apply to nursing:
Lipstick shaped nipples
Thrush of the nipples
1a) How many times a day do you breastfeed/bottlefeed?
1b) If breastfeeding, how long for each side?
2) If you use a shield to breastfeed, you use it for...
Right side only
Left side only
I don't use a breast shield
3) Describe your milk supply:
4a) Have you seen a lactation consultant?
4b) If yes to (4a), whom have you seen and how many visits?
INFANT FEEDING HISTORY
Please check the appropriate boxes as the apply to feeding.
Baby bobs on and off to latch
Baby falls off breast and sleeps
Lips feels weak
Lips cannot retain a pacifier
Tongue feels weak
Tongue cannot retain a pacifier
Loss of suction while nursing
Chronic spitting up
Gulping when feeding
Arches back when feeding
Clenches hands when feeding
Clicking noise when feeding
Baby slides off of the nipple
Breast milk leakage from mouth
Breast milk leakage from nose
Tongue feels like sandpaper
Creases on lip after feeding
If your baby is losing weight, how many pounds?
1a) Was your baby previously diagnosed with a lip or a tongue tie?
1b) If yes, answer the questions below, otherwise skip this section. What was the diagnosis?
Lip and Tongue Tie
Lip and Cheek Tie
Tongue and Cheek Tie
Lip, Tongue and Cheek Tie
1e) By whom?
2a) Has your baby taken or is currently taking any prescribed medications?
2b) If yes please specify which ones, otherwise skip this section.
3) Does your baby still need to have his/her vitamin K shot?
4a) Is there any posture or shoulder tension or head position favoritism? (Eg. turning head to one side mostly). If no, skip to question #5
4b) If favourtism/tension observed, have you brought your baby for bodywork with a Chiropractor, Osteopath, physiotherapy, massage therapist?
5a) Do you supplement with a bottle to assist with proper feeding?
5b) If yes, select all that apply, otherwise skip this section
7) Any other nursing concerns?
Please answer "yes" or "no" to the following questions.
My baby is losing or slow to gain weight.
My baby is gagging, choking, aspirating or has breathing problems due to incorrect sucking.
My baby is experiencing painful gastrointestinal issues (reflux-like symptoms, frequent vomiting, gassiness) arising from swallowing air.
I have contemplated stopping breastfeeding due to the excruciating pain felt when nursing.
I have contemplated stopping breastfeeding due to recurrent block ducts or mastitis (infection of breast).
APPOINTMENT BOOKING AND CONSENT
To help you and your baby, there will be two appointments consisting of a consultation/assessment, and treatment respectively. The consultation will be used to address your feeding concerns, conduct a preliminary assessment to see if a frenectomy is needed, review the frenectomy procedure and answer your questions. If you decide to proceed with treatment, the consent form will be discussed and information about treatment cost and insurance (if applicable) will be provided. Following the consultation, essential resources will be emailed to promote feeding. Please choose an option:
Yes, I wish to book a consultation.
No, I do not wish to book a consultation at this time.
CONSENT: I consent to disclose my personal information to Soni Dentistry for the purposes of a consultation to determine if there is a physical oral problem affecting my ability to breastfeed or bottle feed my baby.
When you press SUBMIT, you will be directed to a BOOKING SCREEN...
wish to book an appointment, please close the window by pressing the "X" in the top right hand corner.
wish to book a
appointment, please choose a time that best suits your schedule. Following the booking, you will:
1) receive a phone call from Soni Dentistry to:
a) clarify questions from your intake form
b) secure your booking time
c) answer any questions you may have
2) receive an email to instruct you
what you need to do,
, to prepare for your consultation appointment.
If you have booked a tentative appointment and
1) HAVE NOT HEARD FROM US OR
2) UNABLE TO BOOK due to a browser conflict, OR
3) the booking date is too far out (we will try and get you in sooner)
Please call the office directly at 519-657-5111.
Thank you for entrusting us with your baby's care.