Referrer should take a full history and observe a feed Baby Yes No Mother Yes No Difficulty in latching Squashed/wedged nipple Clicking noises whilst feeding Nipple pain during feed Fussiness at breast Sore damaged nipples Prolonged/frequent feeding Mastitis/breast infections Prolonged physiological jaundice Exhaustion from frequent feeds Frequently coming of the breast or Psychological effects from difficulty slipping back to the nipple in establishing breastfeeding Excessive early weight loss/gain Family history of blood/ clotting Please specify disorders Has Vitamin K been Any additional information (to be completed by referrer) Ethnicity Please Tick J. Pakistani – A. White British K. Bangladeshi – B. White Irish L. Any other Asian Background – C. Other M. Caribbean – D. Mixed White and Black Caribbean N. African – E. White and Black African P. Any other Black Background – F. Mixed White and Asian R. Chinese – G. Mixed And others S. Any other Ethnic Group – H. Indian Z. Not stated Date referral forwarded to CSH Surrey: 2
Referrer should take a full history and observe a feed Baby Yes No Mother Yes No Difficulty in latching Squashed/wedged nipple Clicking noises whilst feeding Nipple pain during feed Fussiness at breast Sore damaged nipples Prolonged/frequent feeding Mastitis/breast infections Prolonged physiological jaundice Exhaustion from frequent feeds Frequently coming of the breast or slipping back to the nipple Psychological effects from difficulty in establishing breastfeeding Excessive early weight loss/gain Please specify Family history of blood/ clotting disorders Has Vitamin K been Any additional information (to be completed by referrer) Ethnicity – Please Tick J. Pakistani A. White – British K. Bangladeshi B. White – Irish L. Any other Asian Background C. – Other M. Caribbean D. Mixed – White and Black Caribbean N. African E. – White and Black African P. Any other Black Background F. Mixed – White and Asian R. Chinese G. Mixed – And others S. Any other Ethnic Group H. Indian Z. Not stated Date referral forwarded to CSH Surrey: 2
Referral%20Form%20for%20the%20Community%20Tongue%20Tie%20Service%20Feb%202017.docx