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D-Restricted Ltd:®
Health Questionnaire

Please complete your 'Health Questionnaire' below. This is necessary for all appointment types.  I recommend this being completed at the same time as you book your appointment. Failure to do so may result in your appointment being delayed.
Some questions may not be wholly visible if being completed on a mobile phone or small device.

Thank You!

HEALTH  QUESTIONNAIRE
for all appointments.

C-Section Categories:
Category 1: Immediate risk to life of either mother or foetus
Category 2: Maternal or foetal compromise
Category 3: Early birth necessary
Category 4: Elective section for medical or choice reasons
Please include reason for section type/what happened?

Have you had any previous appointments with myself for the child named above?
Has your child received Vitamin K? Required
Is there any family history of diagnosed tongue-tie restriction?
Please tick all of the feeding methods used since birth Required

Potential  symptoms

Please tick all feeding symptoms that occur at least once every 24 hours:

Potential symptoms:

Breast-feeding/Chest-Feeding

Breast per feeding:

Please tick all feeding symptoms that occur at least once every 24 hours

These BREAST FEEDING symptoms DO NOT necessarily mean there is a tongue restriction, and symptoms can be accountable to other causes/situations. This is just to clarify feeding behaviours. At your appointment a tongue function motility assessment and overall review will suggest if a tongue restriction is accountable.
At initial latch-on: is it painful?

Bottle Feeding 
(human or formula milk)

Please tick all feeding symptoms that occur at least once every 24 hours

These BOTTLE FEEDING symptoms DO NOT necessarily mean there is a tongue restriction, and symptoms can be accountable to other causes/situations. This is just to clarify feeding behaviours. At your appointment a tongue function motility assessment and overall review will suggest if a tongue restriction is accountable.

Thank you for submitting! You should now receive an email confirmation to say this has been successfully sent (please also check your junk/spam box if you do not see it in your inbox immediately).

© DIANA WARREN IBCLC, RGN

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Diana Warren;

Registered Nurse (RGN)

International Board Certified Lactation Consultant (IBCLC)

Neonatal Specialist Nurse (QIS)     

LEAARC Infant Feeding Specialist

Independent Tongue-Tie Practitioner

Baby Massage Instructor

Baby/Toddler Yoga Instructor

Orofacial Myofunctional Therapy Provider     Honorary Member of ATP (UK)

Member of IATP (International)

MEDICAL ADVICE DISCLAIMER:
This website does not provide medical advice. The information, including but not limited to text, graphics, images and other material contained on this website are for information purposes only. No material on this site is intended to be a substitute for professional advice, diagnosis or treatment. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.

® D-Restricted Ltd is registered with Companies House No:14109786

© DIANA WARREN IBCLC, RGN

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