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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?

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

Additional related symptoms

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

Additional Symptoms:

Bottle Feeding
(human milk or formula)

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.

Breast/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?

****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****

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,
3)Consent for both assessment and possible frenulotomy
All of these can be read in advance by clicking on the 'Considerations' tab above.
NB the Birthing parent (ie mother) MUST attend the appointment for consent purposes.

**Please scroll down to click Submit!**

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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