INFANTTS Assessment Form

1

Are you anxious and stressed about your baby’s feeding?* This field is required.

YESNO

2

How concerned are you that your baby is unsettled and feeding all the time?* This field is required.

1 = Not concerned at all

2 = Slightly concerned

3 = Somewhat concerned

4 = Moderately concerned

5 = Extremely concerned

3

Does your baby have difficulty latching or staying on the breast or bottle?* This field is required.

1 = No problems

2 = Minor problems

3 = Moderate problems

4 = Major problems

4

How concerned are you about your baby's weight loss/failure to gain weight?* This field is required.

1 = Not concerned at all

2 = Slightly concerned

3 = Somewhat concerned

4 = Moderately concerned

5 = Extremely concerned

5

Does your baby have difficulty controlling milk flow and choke easily?* This field is required.

1 = No problems

2 = Minor problems

3 = Moderate problems

4 = Major problems

6

Does your baby struggle with colic, wind and/or reflux?* This field is required.

1 = No problems

2 = Minor problems

3 = Moderate problems

4 = Major problems

7

Does your baby make clicking noises during feeding?* This field is required.

YESNO

8

Do you have sore, damaged nipples and find it painful to feed?* This field is required.

1 = No problems

2 = Minor problems

3 = Moderate problems

4 = Major problems

9

Do you have engorgement / mastitis?* This field is required.

YESNO

10

Your Results

11

Name* This field is required.

First Name

Last Name

12

Email* This field is required.We may contact you to inform you about upcoming tongue-tie clinics

example@example.com