Home | Frenectomy Evaluation Frenectomy Evaluation Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient is: *— Select Choice —Child / TeenInfantPatient's Name:Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Previous clip of tongue/lip? *YesNoWhen/where:Have any of the following issues been experienced?Speech Issues:Frustration/embarrassment with communicationDifficult to understand by parents (if applicable)Difficult to understand by outsiders% Percent of time you understand your childDifficulty speaking fastDifficulty getting words outTrouble with sounds? (Explain below)Speech delay? (Describe when below)StutteringHarder to understand long sentencesSpeech therapy? (Specify how long below)Mumbling or speaking softlyUses baby voiceDifficulty singingJaw gets tired when talking or reading aloudExplain trouble with which sounds? (if applicable)When is speech delay? (if applicable)Duration of speech therapy? (if applicable)Sleep Issues:Sleeps in strange positionsSleeps restlessly (kicks or moves a lot)Wakes easily or oftenWets the bedWakes up tired and not refreshedGrinds teethMouth OpenSnores (Explain how often below)Gasps for air or stops breathing (sleep apnea)Snores how often? (if applicable)Feeding Issues (as a baby):BreastfedBottle-fedPainful nursing or shallow latchPoor weight gainReflux or spitting upMilk leaked out of mouth/messy eaterPoor milk supplyNipple shield needed for nursingClicking or smacking noise when eatingCried a lot/colic as babyDifficulty transitioning to solid foodsFeeding Issues (currently):Frustrated when eatingSlow eater / doesn’t finish mealsSmall appetite / trouble gaining weightGrazes on food throughout the dayPacks food in cheeksPicky with textures? (Explain which below)Difficulty swallowing pills (if applicable)Affects family dynamics (can’t eat out, etc.)Picky with which textures? (if applicable)Other Related Issues:Neck or shoulder tension or painTMU Pain, clicking, or poppingHeadaches or migrainesStrong gag reflexProlonged thumb sucking / pacifier useMouth open / mouth breathing during the dayTonsils or adenoids removed previouslyEar tubes previously / lots of ear infectionsHyperactivity / inattentionLip-Tie Issues: Difficult or fights to brush top teethTop teeth don’t show when smilingGap between two front teethCavities on front teethTrouble eating from a spoon/flip spoon overTrouble with B, P, M, or W soundsDifficulty breathing through nosePrimary Care Provider:Chiropractor/PT/CT: Speech/Feeding Therapist:Were you referred by someone for this evaluation?Other information the doctor should be aware of?Parent's Signature: Clear Signature Date:MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 experienced? Name: or Patient's Name:Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Previous clip of tongue/lip? *YesNoWhen/where:Birth Weight:Current Weight:Infants are usually given vitamin K at brith. Did your child receive the vitamin K shot?YesNoHas your infant experienced any of the following?Shallow latch at breast or bottleFalls asleep in the middle of a feedSlides or pops on and off the nippleGagging, choking, or coughing when eatingPoor or slow weight gainHiccups oftenSnoring, noisy breathing, or mouth breathingShort sleeping and waking oftenBaby moves a lot in sleep/restless sleepBaby seems always hungry and not fullLip curls under when nursing or taking a bottleClicking or smacking noises when eatingSucking blisters or callouses on lipsColic symptoms / Baby cries a lotGassy (toots a lot) / Fussy oftenMilk leaks out of the mouth when nursing / bottleNose sounds congested oftenBaby is frustrated at the breast or bottleSpits up:occasionallyoftena lot of fluida little fluidHow long does baby take to eat?How often does baby eat?Do you have any of the following sign or symptoms now or in the past?Creased, flattened, or blanched nipplesLipstick-shaped nipplesBlistered or cut nipplesPoor or incomplete breast drainageDecreasing milk supplyBaby prefers one side over other? (Specify which side below)Pain on a scale of 0-10 when first latching? ( Specify below)Pain on a scale of 0-10 when during nursing? ( Specify below)Plugged ducts / engorgement / mastitisNipple thrushUsing a nipple shieldWhich side does baby prefer? (if applicable)RightLeftPain scale of 0-10 when first latching? (if applicable)Pain scale of 0-10 during nursing? (if applicable)Primary Care Provider:Lactation Consultant:Chiropractor/PT/CT: Were you referred by someone for this evaluation?Other information the doctor should be aware of?Parent's Signature: Clear Signature Date:MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Submit
