northstarfamilydental.com - Mother Infant Assessment

Mother Infant Assessment

Infants – Less than one year old
Patient’s Name
Birthday *

Month Day Year
Today’s Date

Month Day Year
Gender

Male Female
Please use this form if your child is Infant
Medical Problems

Heart disease Bleeding disorders Other
Birth Weight
Present Weight
Birth Hospital
Vaginal birth
C-Section Birth
Any birth complications?
Are you presently breastfeeding?

Yes No
If no, how long since you stopped breastfeeding?
Medical History:
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
Has your infant had any surgery?

Yes No
Has your infant experienced any of the following? Please check or elaborate as needed.
Shallow latch at breast or bottle Gumming or chewing your nipple when nursing Falls asleep while eating Pacifier falls out easily Slides or pops on and off the nipple Milk dribbles out of mouth when nursing/bottle Colic symptoms / Cries a lot Short sleeping requiring feedings every1-2hrs Reflux symptoms Snoring, noisy breathing or mouthbreathing Clicking or smacking noises when eating Feels like a full-time job just to feed baby Spits up often. Amount/ Frequency Nose congested often Gagging, choking, coughing when eating Baby is frustrated at the breast or bottle Gassy (toots a lot) / Fussy often Lip curls under when nursing/with bottle Poor weight gain Hiccups often
Spits up often. Amount/ Frequency
How long does baby take to eat?
How often does baby eat?
Is your infant taking any medications?

Reflux Thrush
Name of medication
Has your infant had a prior surgery to correct the tongue or lip tie?

Yes No
If yes, when, where, and by whom?
Do you have any of the following signs or symptoms? Please check and elaborate as needed

Creased, flattened or blanched nipples Poor or incomplete breast drainage Lipstick shaped nipples Infected nipples or breasts Blistered or cut nipples Plugged ducts / engorgement / mastitis Bleeding nipples Nipple thrush Pain when first latching Using a nipple shield Pain during nursing Baby prefers one side over other
Pain on a scale of 1-10 when first latching
Pain (1-10) during nursing
Right / Left?
Pediatrician
Phone Number
Please enter a valid phone number.
Lactation Consultant
Phone Number
Please enter a valid phone number.
Who referred you to us?
Should be Empty:

Mother Infant Assessment

Medical History:

Has your infant experienced any of the following? Please check or elaborate as needed.