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Infant Assessment Form Ages 0-2
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Infant Name
*
First
Last
Birth Date
*
Today's Date
*
Sex
*
Male
Female
Birth Weight
*
Current Weight
*
Birth Location
*
Birth Type
*
Vaginal Birth
C-Section
Any Birth Complications?
Are you breastfeeding or pumping?
*
Yes
No
If no, how long since you stopped breastfeeding?
Infants are usually given vitamin K at birth. Did your child receive the vitamin K shot?
*
Yes
No
Was your infant premature?
*
Yes
No
If yes, how many weeks?
Does your infant have any heart disease?
*
Yes
No
Does your infant have any blood disease?
*
Yes
No
Any other medical conditions?
Has your infant had any surgeries?
*
Yes
No
If yes, what type?
Has your infant experienced any of the following?
*
Shallow latch at breast or bottle
Falls asleep in the middle of a feed
Slides or pops on and off the nipple
Gagging, choking, or coughing when eating
Poor or slow weight gain
Hiccups often
Lots of in utero hiccups
Gumming or chewing the nipple
Pacifier falls out easily or won’t stay in
Snoring, noisy breathing, or mouth breathing
Short sleeping and waking often
Baby moves a lot in sleep/restless sleep
Baby seems always hungry and not full
Lip curls under when nursing or taking bottle
Clicking or smacking noises when eating
Sucking blisters or callouses on lips
Colic symptoms / Baby cries a lot
Reflux symptoms
Spits up often?
Gassy (toots a lot) / Fussy often
Milk leaks out of mouth when nursing/bottle
Nose sounds congested often
Baby is frustrated at the breast or bottle
Constipation or irregular stools
How long does baby take to eat?
*
How often does baby eat?
*
Any other issues or concerns?
infant Do given
Does your infant taking any medications?
Reflux
Thrush
Name of medication?
Any prior surgery to correct the tongue- or lip-tie?
*
Yes
No
If yes, when/where
How are you doing mentally/emotionally?
*
Do you have any of the following signs or symptoms now or in the past?
*
Creased, flattened, or blanched nipples
Lipstick shaped nipples
Blistered or cut nipples
Feelings of hopelessness/depression
Poor or incomplete breast drainage
Decreasing milk supply
Plugged ducts / engorgement / mastitis
Nipple thrush
Using a nipple shield
Baby prefers one side over the other
Right
Left
Pain on a scale of 0-10 when first latching?
*
Pain on a scale of 0-10 when nursing?
*
Primary Care Provider
*
Chiropractor/PT/CST
Lactation Consultant
Other Therapist/Provider
Who referred you to us?
How far away do you live?
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