D-Restricted:

Specialist Infant Feeding Support

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07910608179

diana@tongue-tie.info

https://www.facebook.com/groups/219881955258950

ADVANCE NOTICE:
Due to Clinic renovations and building works I will be unavailable for clinic consultations & tongue tie divisions from:
Sunday 18th July until Friday August 27th 2021.
I will keep this website updated with any changes.
All new and existing patients up until this date will continue to receive my support throughout this period.
Alternative tongue tie practitioners may be found at:
www.tongue-tie.org.uk/find-a-practitioner
For lactation support please refer to www.lcgb.org
or for telephone support with a breastfeeding counsellor you may choose to telephone 0300 100 0212
Thank you for your understanding.

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.

Date of Recent Weight

My infant is formerly registered at this practice

This is my infant's intended GP practice, but is not formely registered here yet (if this is the case the gestational parent must already be registered there)

My infant is registered at this practice as a temporary patient only.

Do you have a named social worker or child protection order insitu? If you have a named social worker please disclose this information as I may need to contact them.

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

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

Yes

No

****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:

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?

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.

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

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.

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

At initial latch-on: is it painful?

0=No Pain

1=Mild Pain

2=Considerable Pain

3=Excrutiating Pain

Not Applicable

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 infant use a dummy/pacifier? (please bring to the appointment)

Does your little one require the use of a nipple shield in order to maintain latch? (if yes, please bring to the appointment)

I accept the Terms & Conditions (found in the 'Considerations' tab)View Terms & Conditions

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

Date Form Completed

Date of Booked Face:Face Appointment

What is the ethnic minority group of the primary caregiver?

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!

Thank you for submitting!

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

© DIANA WARREN IBCLC, RGN

Diana Warren;

Registered Nurse (RGN),

IBCLC (International Board Certified Lactation Consultant),

Neonatal Specialist Nurse (QIS),

Breastfeeding Counsellor (ABM),

LEAARC Infant Feeding Specialist,

Independent Tongue-Tie Practitioner,

Baby Massage Instructor &

Baby/Toddler Yoga Instructor

© 'D-Restricted: Specialist Infant Feeding Support' created with Wix.com (2014)