Download Printable Version

Lip and Tongue Tie Assessment

Has your child experienced any of the following problems or treatment?

1. Has the infant experienced any of the following?

Poor Latch
Falls asleep while attempting to nurse
Slides off the nipple when attempting to latch
Colic symptoms
Reflux symptoms
Poor weight gain
Gumming/chewing of your nipple when nursing
Milk coming out the nose or side of mouth when nursing
Unable to hold a pacifier in his/her mouth
Short sleep cycles
Feedings every 2 hours or less
Clicking while nursing

2. Has the infant received any cranio-sacral therapy (CST)?

Has the infant received any cranio-sacral therapy (CST)?

3. If so, was there improvement?

If so, was there improvement?

4. If so, was the improvement lasting?

If so, was the improvement lasting?

5. Is your infant under the care of a Chiropractor?

Is your infant under the care of a Chiropractor?

6. If so, was there improvement?

If so, was there improvement?

7. If so, was the improvement lasting?

If so, was the improvement lasting?

8. Does the mother have any of the following signs or symptoms?

9. Other comments on nursing?

Clinically/Visually

10. Does the upper lip flange out while feeding at the breast?
11. Does the upper frenum attach near the wet/dry line of the upper lip?
12. Upper frenum attaches at the bottom of the gum ridge?
13. Does the lower frenum attach at the anterior 1/3 of the tongue?
14. Is there a "speed bump" when you sweep your finger side to side under the tongue?
15. If yes, does it physically stop your finger from crossing the midline?
16. Is there a "piano wire" or tight rope that pops out when you run your index finger from the gum ridge towards the back of the throat under the tongue along the midline?
17. Does the tongue stay low in the mouth when crying or look spoon shaped when crying?
Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue