Survey

Child's Name

Child's Age

Baby Issues (Past or Present)

Painful nursing or shallow latch

Difficulty bottle-feeding

Slow or poor weight gain

Reflux or spitting up often

Excessive gassiness or fussiness

Prolonged feeding time at the breast or on the bottle

Milk dribbling out of the mouth while feeding

Clicking or smacking noise while feeding

Child to Adult Issues

Frustration with communication

Trouble with speech sounds, hard to understand, or mumbling

Speech delay

Slow eater or trouble finishing a meal

Picky eater, especially with textures (e.g. meat, mashed potatoes)

Choking or gagging on liquids or foods

Spitting out food or packing food in cheeks

Crooked, crowded teeth, or highly-arched palate

Thumb or finger sucking or prolonged pacifier use

Restless sleep (kicking or moving while asleep)

Grinds teeth at night

Sleeps with mouth open

Snores (quiet or loud)

Jaw joint (TMJ) issues (popping, clicking, or pain)

Frequent headaches or neck pain

Mouth breathing during the day

Enlarged tonsils and/or adenoids

Recurrent ear infections

Frequent sinus issues/upper respiratory infections

Hyperactivity or inattention

Email

Phone Number

May we contact you to discuss the results?

Does your child have a Tongue-Tie?