Patient's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Family history of bleeding disorder? *

such as Haemophilia/ Von Willebrands

Yes

No

Patient was given Vitamin K at birth? *

Yes

No

There is a suspicion of an oral or facial abnormality? *

such as cleft lip or palate

Yes

No

Infants Symptoms *

Difficulty latching onto the breast

Clicking sounds whilst feeding

Poor weight gain of failure to thrive

Baby unsettled/ hungry most of the time/ colic

Prolonged feeds with short breaks

Significant dribbling during feeds

Maternal Symptoms *

Nipple pain / erosion

Painful breasts

Low milk supply

Mastitis

Feeding *

Exclusive Breastfeeding

Expressing / Pumping

Using Nipple Shields

Supplementation with formula

Percentage of feeds not breastfeeding

Tongue Function / Restriction *

Extension

Lateralisation

Elevation

Appearance *

Anterior

Posterior

Referring Practitioner Name *

First Name

Last Name