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.
PERSONAL DETAILS
Please enter the personal details of your INFANT below.
Title
Mr.
Mrs.
Ms.
Mstr.
Miss
Dr.
First Name
Last Name
Preferred Name
Gender
Female
Male
Non-Binary/Other
Unspecified/Prefer Not To Answer
Date of Birth
Address
Address 2
Province/State
City
Postal /Zip Code
Home #
Work #
Ext.
Mobile #
Other #
Preferred Phone
Home
Work
Mobile
Other
Email
Contact Method
Email
Phone
Mail
Sms
Employer/School
Occupation
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 Relation
Emergency Phone #
PARENT CONTACT INFORMATION
Mother's Name:
Father's Name:
Best time to contact you:
Parent Email:
INFANT BIRTH INFORMATION
Birth Weight:
Current Weight:
Birth History:
Hospital
Home
Full Term:
Yes
No
Number of weeks:
Birth Details:
Vaginal
C-Section
Forceps
Vacuum
N/A
Physician's Name:
Physician's Address:
Midwife's Name:
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:
Breastfeeding
Bottlefeeding breastmilk
Bottlefeeding formula
Tube feeding
Syringe feeding
Nipple Shield
Other
Please check the appropriate boxes as the apply to nursing:
Painful nursing
Bruised nipples
Cracked nipples
Everted nipples
Flat nipples
Inverted nipples
Blistered nipples
Blanched nipples
Flattened nipples
Lipstick shaped nipples
Bleeding nipples
Swollen breast(s)
Clogged duct(s)
Mastitis
Thrush of the nipples
Not Applicable
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
Both sides
I don't use a breast shield
3) Describe your milk supply:
Strong letdown
Adequate
Losing supply
Uncertain
Not applicable
4a) Have you seen a lactation consultant?
Yes
No
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.
Prolonged/incomplete 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 burping
Chronic flatulence
Chronic hiccups
Distended belly
Bloated belly
Chronic spitting up
Gagging
Vomiting
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?
Yes
No
1b) If yes, answer the questions below, otherwise skip this section. What was the diagnosis?
Lip Tie
Tongue Tie
Cheek Tie
Lip and Tongue Tie
Lip and Cheek Tie
Tongue and Cheek Tie
Lip, Tongue and Cheek Tie
Unsure
1c) When?
1d) Where?
1e) By whom?
2a) Has your baby taken or is currently taking any prescribed medications?
Yes
No
2b) If yes please specify which ones, otherwise skip this section.
3) Does your baby still need to have his/her vitamin K shot?
Yes
No
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
Yes
No
4b) If favourtism/tension observed, have you brought your baby for bodywork with a Chiropractor, Osteopath, physiotherapy, massage therapist?
Yes
No
5a) Do you supplement with a bottle to assist with proper feeding?
Yes
No
5b) If yes, select all that apply, otherwise skip this section
Breast Milk
Formula
Both
6) Diapers
Yellow
Green
Brown
Seeded
Mucous
Bloody
7) Any other nursing concerns?
OTHER
Please answer "yes" or "no" to the following questions.
My baby is losing or slow to gain weight.
Yes
No
My baby is gagging, choking, aspirating or has breathing problems due to incorrect sucking.
Yes
No
My baby is experiencing painful gastrointestinal issues (reflux-like symptoms, frequent vomiting, gassiness) arising from swallowing air.
Yes
No
I have contemplated stopping breastfeeding due to the excruciating pain felt when nursing.
Yes
No
I have contemplated stopping breastfeeding due to recurrent block ducts or mastitis (infection of breast).
Yes
No
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.
Yes
No
When you press SUBMIT, you will be directed to a BOOKING SCREEN...
If you
do not
wish to book an appointment, please close the window by pressing the "X" in the top right hand corner.
If you
do
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 our baby co-ordinator at Soni Dentistry to:
a) clarify questions from your intake form
b) confirm your booking time
c) answer any questions you may have
2) receive an email to instruct you
what you need to do,
before Tuesday
, to prepare for your consultation appointment.
If you:
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.
