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Specialist Infant Feeding Support

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Health Questionnaire

Please complete your 'Health Questionnaire' below. This is necessary for both the Mini-Consultations and Home Visits ONLY

Thank you for your co-operation!

The 'Health Questionnaire' is NOT required for clinic visits. Thank you

HEALTH QUESTIONNAIRE

for FREE Mini-Consult @ Tummy2Mummy & home visits

Date of Recent Weight

Have you had any previous appointments with myself for the child named above?

Yes

No

Has your child received Vitamin K?

Yes by injection at birth

1 of 3 oral doses received

2 of 3 oral doses received

oral course completed

Vitamin K declined

Unsure

Mini-Consults are NOT

CURRENTLY

AVAILABLE

Please tick all of the feeding methods used since birth

Breastfeeding

Bottle feeding with formula

Bottle feeding with your own expressed milk

Bottle feeding with donor milk

Spoon feeding milk

Cup feeding

Syringe feeding

Finger feeding

Tube fed (NG/OG/NJ)

TPN (in hospital)

Supplemental Nursing System (SNS)

Intravenous fluids

Introducing solids

Does your child use a dummy/pacifier/soother?

Additional Related Symptoms

Reflux/Silent Reflux

Frequent Hiccoughs (daily)

Frequent Sneezing (daily)

Grunting/Snuffly/upper airway noises

Audible heavy breathing/snoring

Unsettled sleeper/"Cat-napping"

Bottle Feeding

Do you use a milk preparation machine?

Feeding Symptoms (please tick all that apply). These 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.

Initial anger/frustration to feed

Shallow latch onto teat

Infant oral thrush

Feeding aversion

Vommitting/Possetting/Spit-up after majority of feeds

Tires to feed

Noises during a feed (kissy, slurpy noises or clicking)

Trapped wind/colic

Struggling with the flow of the milk

Sucking blisters to lips/ poor lip tone

Dribbling milk during a feed

Gagging or wretching during a feed

Crushing bottle teat with gums during a feed

Pushing teat in and out during a feed like a piston

Bottle teat rejection

BreastFeeding

Feeding Symptoms (please tick all that apply). These 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.

Initial anger or frustration to feed

Nipple shape/colour change after a feed

Shallow latch onto nipple

Unable to maintain latch/Slips down into a shallow latch or relatches

Poor breast drainage/Engorgement

Nipple or child oral thrush

Blocked ducts&lumps/blebs/blisters/mastitis/abcess

Feeding aversion

Vommitting/Possetting/Spit-up after majority of feeds

Tires to feed

noises during a feed (kissy slurpy noises or clicking)

Trapped wind/colic

Sucking blisters to lips/poor lip tone

struggles to adapt to milk flow (gulping, coughing, stopping)

Dribbling milk during a feed

Pain/Vasospasm/Cracked or bleeding nipples

Gagging or wretching during a feed

****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****

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I have read and AGREE to the Privacy Notice (found in 'Considerations' tab)View Privacy Notice

Date Form Completed

Date of Appointment booking

Thank you for submitting!

You should receive an email confirmation to say this has been successfully sent.

Mini-Consults are NOT

CURRENTLY

AVAILABLE

Diana Warren;

Registered Nurse (RGN), IBCLC (International Board Certified Lactation Consultant), Neonatal Specialist Nurse (QIS), Breastfeeding Counsellor (ABM), LEAARC Lactation Specialist, Independent Tongue-Tie Practitioner, Baby Massage & Baby/Toddler Yoga Instructor

D-Restricted:

Specialist Infant Feeding Support

Health Questionnaire

Please complete your 'Health Questionnaire' below. This is necessary for both the Mini-Consultations and Home Visits ONLY

Thank you for your co-operation!

The 'Health Questionnaire' is NOT required for clinic visits. Thank you

HEALTH QUESTIONNAIRE

for FREE Mini-Consult @ Tummy2Mummy & home visits

Mini-Consults are NOT

CURRENTLY

AVAILABLE

Bottle Feeding

BreastFeeding

Mini-Consults are NOT

CURRENTLY

AVAILABLE

Diana Warren;

Registered Nurse (RGN), IBCLC (International Board Certified Lactation Consultant), Neonatal Specialist Nurse (QIS), Breastfeeding Counsellor (ABM), LEAARC Lactation Specialist, Independent Tongue-Tie Practitioner, Baby Massage & Baby/Toddler Yoga Instructor

Regulated by Care Quality Commission (CQC) with Enhanced DBS certification