Home | Frenectomy Follow-Up Evaluation Frenectomy Follow-Up 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 Birth:MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of Procedure:MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Instructions: Please mark any previous issues that saw improvement.Speech:Easier to communicateEasier to understand by parents (if applicable)Easier to understand by outsidersEasier to speak fast or long sentencesEasier to get words outEasier with sounds? (Explain below)New words? (List below)Get less tired when talking or reading aloutTalking more (or more babbling)Les stutteringLess mumbling or spaeking softlyLess “baby talk”Can talk or sing louder nowExplain which sounds are easier? (if applicable)What new words can they pronounce? (if applicable)Sleep:Less sleeping in strange positionsLess moving around at night (less restless)Sleeping deeper and waking less oftenLess wetting the bed (if applicable)Wakes up less tired and more refreshedLess grinding teeth while sleepingLess sleeping with mouth openLess snoring while sleepingLess gasping for air or stopping breathingFeeding:Less frustration when eatingEasier to eat/swallow solid foodsEating fasterEating more foodFinishing meals better / less grazing on foodsEasier to swallow pills (if applicable)Trying new foodsLess packing food in cheeksLess picky with textures (Please specify below)Less choking or gagging on food and/or liquidsLess spitting out foodEasier to clean teeth off with tongueLess picky with which textures? (if applicable)Other Related Issues:Less neck or shoulder tension or painLess TMJ Pain, clicking, or poppingFewer headaches or migrainesLess strong gag reflexLess mouth open / mouth breathing during the dayLess refluxWalking or crawling better / more flexibleBetter attention span / less hyperactivity issuesEasier to brush top teeth (after lip-tie releaseEasier to breathe through noseLess stress / anxietyPlease write anything the worsened here:Were you able to stretch the sites exactly as directed?YesNoHow much change in speech did you see from the release?Much betterBetterNo changeWorseMuch WorseNo prior issuesHow much change in sleep did you see from the release?Much betterBetterNo changeWorseMuch WorseNo prior issuesHow much change in feeding did you see from the release?Much betterBetterNo changeWorseMuch WorseNo prior issuesLooking back, if you "had to do it all over again" would you?YesProbablyDon't think soNeverParent's Signature: Clear Signature Today's Date:MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 the back, does Patient's Name:Date of Birth:MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of Procedure:MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Birth Weight:Weight at initial visit:Weight today:Instructions: Please mark any that apply.Has your infant experienced any of the following?Deeper latch at breast or bottleLess falling asleep while eatingSlides or pops on and off the nipples lessLess colic symptoms/cryingLess refluxLess clicking or smacking noisesLess spit upLess gagging, choking, coughing when eatingLess gassy / Less fussyLess constipation, more regular stoolsBetter weight gainHappier baby than beforeLess hiccupsLips flip out better / not curling under as muchLess gumming or chewing the nipplePacifier stays in betterMilk dribbles / leaks out of mouth lessSleeping longerLess snoring or mouth breathingLess moving around in sleepNose congested less oftenBabbles more or makes new soundsLess frustrated at the breast or bottleEats solid foods better (if applicable)How long does baby take to eat?How often does baby eat?Please write anything that worsened here:If mom is nursing, has she noticed any changes since the procedure?Less creased, flattened or blanched nipplesLess lipstick shaped nipplesLess blistered or cut nipplesLess nipple bleedingSignificantly less painSomewhat less painImproved breast drainageLess infected nipples or breastsLess plugged ducts / engorgement / mastitisLess nipple thrushLess use of a nipple shieldBaby doesn’t prefer one side over the otherBetter milk supplyPain before procedure (scale of 1-10):Pain now (scale 1-10):Were you able to stretch the sites exactly as directed?YesNoHow was your experience at Kids Dental Experts?Looking back, if you "had to do it all over again", would you?YesProbablyDon't think soNeverParent's Signature: Clear Signature Today's Date:MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Submit
