1. Do You Have An Appointment?

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  3. You need to make an appointment to continue. Please click here to request an appointment
  1. Your First Name
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  2. Last Name
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  3. E-mail
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  4. Preferred Contact Number
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  5. Birth History

  6. Child's Name
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  7. Child's Date of Birth
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  8. Birth Weight
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  9. Current Weight
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  10. Birth Location
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  11. Full Term
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  12. Birth Type
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  13. Forceps/Vacuum Assisted
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  14. Mother Questions

  15. Do you have any of the following (please check all that apply).






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  16. Do you use a shield to breastfeed?
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  18. How many times a day do you breastfeed?
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  19. How long for each side?
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  20. Baby Questions

  21. Was your baby previously diagnosed with a lip or tongue tie?
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  22. Was it treated somewhere else?
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  23. When?
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  24. Where?
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  25. By Who?
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  26. Has your baby taken or is currently taking any prescribed medications?
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  27. Which Medications?
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  28. Has your baby had his/her Vitamin K shot?
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  29. Have you seen a Chiropractor or CST for your baby?
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  30. Is there any posture or shoulder tension or head position favoritism?
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  31. When nursed is the feeding...

















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  32. Is your baby losing weight?
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  33. How much?
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  34. When nursing does it feel like there is...
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    Choices: Drinking, Gulping, Both, None
  35. Do you supplement with a bottle to assist with proper feeding?
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    Choices: No, Yes with breastmilk, Yes with formula, Yes with both
  36. Is there a sustained strong or clamping latch?
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  37. Any other nursing concerns?
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