Periodontics/Implants/Tethered Oral Tissues Form

Please correct the errors described below.

Patient Name:

Date of Birth:

Parent #1's Name:

Date of Birth:

Parent #2's Name :

Date of Birth:

Referring Professional:

Lactation Consultant:

Phone #’s:

Orofacial Myotherapist:

Medication Allergies:

Current Medications: (Including Over The Counter, herbal, vitamins)

Past Medical History:

Birth Weight (lb/oz):

Present Weight:

Received Vitamin K injections:

Yes No

Was your infant premature:

Yes No

If yes Gestational Age (weeks)

Does your infant have Heart Disease:

Yes No

If yes:

Has your infant had any surgery:

Yes No

If yes:

Has your infant had prior surgery to correct tongue or lip tie:

Yes No

If yes, when/by whom:

Are you or will you be seeing a myo-functional therapist?

Yes No

If no, reason why:

Baby Symptoms:

Poor Latch

Nasal Obstruction

Cyanosis (turning blue)

Falls asleep while attempting to nurse

Slides off nipple when attempting to latch

Colic Symptoms

Breathing Issues

Bleeding Problems

Reflux Symptoms

Swallowing Issues

Vomiting

Poor weight gain

Weight Loss

Gumming or chewing of nipple when nursing

Unable to hold pacifier in mouth

Short sleep episodes requiring feeding every 2-3 hours

Mother’s Symptoms:

Creased, Flattened / Blanched Nipples post nursing

Cracked, bruised or blistered nipples

Bleeding Nipples

Severe pain when infant attempts to latch

Poor or incomplete breast drainage

Infected nipples or breasts

Plugged ducts

Mastitis or nipple thrush

Family history of Tongue or Lip Tie

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