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 for your co-operation!

HEALTH  QUESTIONNAIRE
for all appointment types.
Has your child received Vitamin K?
Have you had any previous appointments with myself for the child named above?

****IF YOUR INFANT HAS ALREADY SEEN A DIFFERENT PRACTITIONER, (EITHER PRIVATE OR NHS) IN THE FIRST INSTANCE PLEASE CONTACT YOUR ORIGINAL PRACTITIONER FOR THEIR SUPPORT AS THEY HAVE ACCESS TO YOUR INFANT'S ORIGINAL MEDICAL RECORDS, AND THEY REMAIN YOUR ACCOUNTABLE PRACTITIONER. 

IF THIS IS  NOT POSSIBLE PLEASE DISCUSS WITH ME VIA TELEPHONE

BEFORE YOU BOOK

ANY CONSULTATION WITH ME   07910608179****

Additional Related Symptoms:

Bottle Feeding

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 casues/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.

Breast 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 casues/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?
Please tick all of the feeding methods used since birth
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Please be advised that at your face:face appointment you will be asked to sign that you have read and agree to:

1) the Terms and Conditions,

2) the Privacy Notice,

and whilst the COVID-19 pandemic continues:

3)Infection Control protocol.

All of these can be read in advance by clicking on the 'Considerations' tab above.

Please scroll down to click Submit!

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You should then receive an email confirmation to say this has been successfully sent (please also check junk/spam box).

© DIANA WARREN IBCLC, RGN