Skip to content
Toggle Navigation
About
Dr Hany
Dr Camillo
Therapy Dog
Denti-Care Payment Plan
QIP Accreditation
Services
Emergency Dental Service
Lip and Tongue Tie
Frenectomy
How do we Treat Lip & Tongue Tie
Lip Tie Symptoms
What Are The Benefits Of Treatment?
Snipping Vs Laser
Effect Of Not Treating
Craniofacial Therapy
What’s Our Approach
Post-Operative Care Following Frenectomy
Treatment in Mackay QLD
Resources
Pre-Orthodontics
Pre-Orthodontic Appliances
Orthodontics
Clear Aligners
Repairs & Breakages
Orofacial Myology
What Does an OM Program Involve?
Airways and Sleep in Children
Jaw Play for Toddlers
OM and Orthodontics
OM for Adults
OM for Kids
Thumb Sucking Program
Paediatric Dentistry
What makes us different?
Quality Care
Special Needs
Sedation Dentistry
Advice
Blog
Contact
DentalCareXtra Marian
DentalCareXtra Moranbah
Careers
Dentist
Locum Dentist
Oral Health Therapist
Dental Assistant
Forms
Professional
Referral to Oral Health & Beyond Collective for General Anesthetic or other Specialised Dentistry Services
Patient
Communication Form
Join the Club
Kids Form
OHB Medical for Children aged 18 months to 17 years
Mackay (07) 4942 5111
Tongue & Lip Tie Release
Aziz
2023-03-10T14:45:34+10:00
Infant Medical - for Tongue & Lip Tie Release
New Child
Patient First Name
Patient Last Name
DOB
MM slash DD slash YYYY
Practice Location
---select---
Moranbah
Mackay
Emerald
Gender
---select--
Male
Female
Other
Parent 1 First Name
*
Parent 1 Last Name
*
Parent 1 Relationship to Child
Parent 2 First Name
*
Parent 2 Last Name
*
Parent 2 Relationship to Child
*
Address
address
Postcode
Email
Mobile Phone
Name of GP
GP Phone
Feeding consultant, e.g Lactation Consultant, Speech Therapist
Who can we thank for referring you?
Pregnancy History
This information is collected to understand your child’s growth, development and health.
Any medications / drugs / supplements taken prior to and /or during pregnancy?
Yes
No
If so, details
Please select your answers. (0 = Low, 5 = High)
What was your average stress level during pregnancy?
0
1
2
3
4
5
Rate your level of fear about labour?
0
1
2
3
4
5
Rate emotional stress? Eg. Lost loved one/moving house or location
0
1
2
3
4
5
Rate depression levels experienced?
0
1
2
3
4
5
Rate anxiety levels experienced?
0
1
2
3
4
5
Did you feel supported by family and friends during pregnancy?
0
1
2
3
4
5
Birth History
Please describe your child’s birth.
Was your child born:
---select---
Vaginally Unassisted
Assisted Forceps
Assisted Vacuum
Emergency C-Section
Planned C-Section
Induced
Gestation at Birth (weeks)
Birth weight (kgs)
Current weight (kgs)
What child number is this for you?
*
First Baby
2
3
4
more
Was / were the following drugs used?
Oxytocin / Syntocinon
Spinal Anaesthesia
Epidural
Spinal Block
Narcotics (Pethidine/ Morphine)
Gas
Did the mother need medical support after labour?
Yes
No
If so, details
Did the child recover well after birth?
Yes
No
If so, details
Did the child wake itself up to feed?
Yes
No
0-14 days how long was their sleep?
<1 hr
1-2hrs
2-3hrs
3+hr
Has your child been examined for development, posture, activity levels, and physical stress? Eg. Muscle tone, postural habits, arching of head?
Yes
No
If so, details
What Hospital or Birthing Centre did you attend?
*
After birth was your child examined for tongue and lip tie or any other functional restrictions?
Yes
No
Profession
Name
Practice
Has your child had their lip and/or tongue tie previously released?
Yes
No
Profession
Name
Practice
Proposed Support
Health History
Has your child experienced any of the following problems or treatment?
Received Vitamin K injections or orally.
Yes
No
If so, details
Cyanosis (turning blue)
Yes
No
If so, details
Poor weight gain
Yes
No
If so, details
Does your infant have heart disease
Yes
No
If so, details
Is your child a mouth breather
Yes
No
If so, details
Upper respiratory infections
Yes
No
If so, details
Any milk or food intolerances /allergies
Yes
No
If so, details
Has your infant had any surgery
Yes
No
If so, details
Diarrhoea
Yes
No
If so, details
Swallowing Issues
Yes
No
If so, details
Skin rashes, eczema or dermatitis
Yes
No
If so, details
Constipation
Yes
No
If so, details
Breathing issues
Yes
No
If so, details
Nasal obstruction
Yes
No
If so, details
Bleeding problems
Yes
No
If so, details
Is your infant taking any medications or supplements?
Yes
No
If so, details
Development / Nutrition
What was your child’s first milk?
Breast only
Formula
Both
How did he/she initially feed?
Breast
Bottle
Tube feeding
How is your child fed now
If mother and child experienced breastfeeding challenges please provide details:
Has your child commenced eating solids?
Yes
No
Are they experiencing any issues (for example: gagging, swallowing, fussy about texture)?
Yes
No
If so, details
Is your child using a pacifier/dummy?
*
No
Yes quite a lot
Sometimes -Only to pacify
Is your child reaching milestones within anticipated time frames?
Yes
No
If so, details
Have you experienced any of the following symptoms?
Poor latch / difficulty latching to breast and/or bottle
Fussiness and arching away from the breast
Gumming or chewing of the nipple/teat when nursing
Slides on and off nipple when attempting to latch
Reflux/Colic Symptoms
Heavy breathing / Snoring / Grinding
Makes clicking noise when suckling
Short sleep episodes requiring feeds every 1-2 hours (day and night) Falls asleep when nursing without finishing full feed
Unable to maintain breast tissue or pacifier in mouth
Choking on milk or popping off breast to gasp for air
Excessive drooling
Explosive, frothy bowel motions
Have you experienced any of the following symptoms?
Creased, flattened or blanched nipples after nursing
Cracked, bruised or blistered nipples
Severe pain when your infant attempts to latch or suckle
Mastitis or blocked duct
Using a nipple shield
Are you expressing milk or have you had to supplement your infant
Bleeding Nipples
Infected nipples or breasts
Poor or incomplete breast drainage
Nipple thrush
Low or compromised milk supply
Any Family History? (that you are aware of)
Tongue Tie
Lip Tie
Do you have any other concerns that we have not included in the above that you would like to discuss further?
I understand that this information is correct to the best of my knowledge. I understand it will be held in the strictest confidence and only used to improve the quality of service my child receives. I further understand that payment is due on the day of my child’s appointment.
Yes
28895
Page load link
Go to Top