Intake and History of Symptoms

Birth History

• Vaginal/C-Section
• Forceps or Vacuum
• Fast Vaginal- less than 30 min of pushing
• Position in utero: normal, breech, sunny side, transverse, leg first, arm first, cord around neck other
• Drugs used: Pitocin, other
• How much I.V. Fluid were you given?
• Skin to skin

Mother- History

• Painful nursing
• Nipples- bruised, cracked, everted, flat, inverted, blistered, blanched, flattened, lipstick shaped, bleeding or misshaped nipples after nursing
• Breast swelling or Clogged ducts, Mastitis
• Thrush of the nipples
• Milk supply: strong letdown, adequate, losing supply, not certain
• Have you altered your diet? Y/N If yes, why?

Mother History Con't

• Do you use a shield to breastfeed? Right – Left –Both sides
• Have you had any breast surgery or trauma? Reduction-Augmentation - Other i.e. Piercings (circle)
• How many times a day do you breast or bottle feed? How long for each side?
• Are you able to feel a let down? Some can, some cannot.

Infant History

• Has your baby been previously diagnosed with a lip or tongue tie? If yes, was it treated somewhere else?
• Has your baby taken or is currently taking any prescribed medications? If yes, which ones?
• Has your baby had his/her Vitamin K drops or shot?
• Is there a family history of tongue or lip ties?
• Have you seen a Chiropractor, Osteopath, PT or CST for your baby?
• Can your baby sleep flat? i.e. sleeps with head arched back?
• Is there any posture or shoulder tension or head position favoritism? i.e. sleeps with head arched back?