HEALTH QUESTIONNAIRE for all appointment types.
My infant is formerly registered at this practice
C-Section Categories: Please include reason for section type/what happened?
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.
Has your child received Vitamin K?
Please tick all of the feeding methods used since birth
Does your little one require the use of a nipple shield in order to maintain latch? (if yes, please bring to the appointment)
Is there any family history of diagnosed tongue-tie restriction?
Have you had any previous appointments with myself for the child named above?
Additional Related Symptoms:
Bottle Feeding (human milk or formula)
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.
Did Breastfeeding complications lead to you needing to bottle feed?
Does your infant use a dummy/pacifier? (please bring to the appointment)
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?
****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 ****
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, 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!** 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).
