A. Meric O'Grady - Speech and Language Pathology

Baby Clinic Intake Form

Please fill in as many fields as possible.

Child Information

Child's Name

Age

Birthdate

Address

City

State

Home Phone

Work Phone

Mobile Phone

Referred By

Child's Doctor

Lactation Consultant

Facility

Do we have permission to contact your lactation consultant? Yes No

Family Information

Mother's Name

Mother's Occupation

Father's Name

Father's Occupation

Caregiver(s)

Relation

Birth history

Length of Pregnancy

Birth Weight

Complications During Birth?

Please explain any difficulties experienced during pregnancy

Sucking Difficulties?

Feeding Difficulties?

Reflux?

Lack of Oxygen?

Breathing Difficulties?

Head Injuries?

Fetal Monitor Use?

What are your main concerns?

Do you have any concerns about lip or tongue-tie? Lip Tongue N/A

Has your baby had a frenectomy? Yes No

Were improvements in feedings observed after frenectomy? Yes No

Are you currently breast or bottle-feeding? Yes No

Are you pumping or supplementing with formula? Yes No

How much?

How often?

When feeding, how many ounces are transferred and how long does it take?

Ounces Via Breast in

How Many Minutes

Ounces Via Bottle in

How Many Minutes

On average, how many ounces are consumed each day?

In what position is your baby fed?

Are you experiencing any soreness during feeding? Yes No

Are you experiencing any bleeding or cracked nipples from feeding? Yes No

Are you using a nipple shield? Yes No

Are you experiencing any latching issues? Yes No

If yes, when are issues present? Breast Bottle

Does your baby fall asleep during feedings? Yes No

Does your baby wake up hungry shortly after feedings? Yes No

Does your baby cry to eat? Yes No

Do you notice your baby's jaw quivering during or following feeding? Yes No

Are you noticing any spillage during feeding? Yes No

Please list any food allergies your baby may have:

Please list any food allergies the baby's mother may have:

Please describe if your baby has experienced any Reflux and how often:

Does your baby seem fussy or uncomfortable following feedings? If so, describe:

Is your baby coughing or choking during feeding? How often?

On average, how many wet diapers per day?

On average, how many dirty/bowel diapers per day?

Medical History

How would you describe your infant’s current health status? Good Fair Poor

Please list any illnesses and/or injuries with associated fevers, after effects, and the age of occurrence:

Any operations? Please describe:

Ear infections?

Frequent colds?

Bronchitis or respiratory infections?

Pneumonia?

Other illnesses? Please describe:

Is your baby on any medications? Please list:

Please explain your concerns about your infant’s feeding habits and/or physical development:

Please state in your own words what difficulties your infant has during feedings:

Has child had a hearing evaluation?

When?

Where?

Results

May we use your infant’s information for research and/or other study purposes? Yes No

Note: The Baby Clinic is a $100 fee paid via cash or check. We do not accept credit cards.

Completed By (Your Name)

Email Address

Relationship to Child

Date

20230628

A. Meric O'Grady Speech and Language Pathology LLC

Baby Clinic Intake Form

Child Information

Family Information

Birth history

Medical History

A. Meric O'Grady
Speech and Language Pathology LLC