Infant Tongue-Tie Assessment Form
Complete this form to help assess feeding concerns and possible tongue-tie in an infant.
Infant Information
Infant's Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Sex/Gender
Female
Male
Intersex
Prefer not to say
Other
Gestational Age at Birth (weeks)
Birth Weight (lbs)
Parent or Guardian Information
Parent or Guardian Full Name
*
First Name
Middle Name
Last Name
Relationship to Infant
*
Please Select
Mother
Father
Grandparent
Legal Guardian
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
*
Phone
Email
Text Message
Other
Feeding Background
Current feeding method
*
Breastfeeding
Bottle-feeding
Combination feeding
Expressed milk
Formula
Other
Feeding frequency
*
Are there any feeding concerns?
*
Yes
No
Tongue-Tie Symptom Assessment
Tongue-Tie Symptom Assessment
*
Rows
Never
Sometimes
Often
Always
Latch difficulty
1
2
3
4
Clicking sounds during feeding
5
6
7
8
Prolonged feeds
9
10
11
12
Milk leakage from mouth
13
14
15
16
Poor suction
17
18
19
20
Gassiness
21
22
23
24
Choking or coughing during feeds
25
26
27
28
Nipple pain for parent
29
30
31
32
Infant fussiness at breast or bottle
33
34
35
36
Overall symptom severity
*
None
1
2
3
Severe
4
1 is None, 4 is Severe
Growth and Oral History
Concerns About Weight Gain
*
No concern
Some concern
Significant concern
Unsure
Prior Weight Checks or Growth Notes
Family History of Tongue-Tie or Related Feeding Issues
Yes
No
Unsure
If yes, please provide details
Prior Evaluation or Procedure Related to Tongue-Tie
Yes
No
Unsure
If yes, please provide details
Clinical Observations and Additional Notes
Observed tongue mobility or oral restriction
*
Normal
Mild restriction
Moderate restriction
Severe restriction
Can tongue extend past the gum line or lip?
*
Yes, easily
Yes, with difficulty
No
Unable to assess
Visible signs observed
Heart-shaped tongue tip
Tight frenulum
Limited tongue lift
Limited tongue extension
Visible blanching
Other
Additional notes or concerns
Acknowledgment and Authorization
Signature
*
Submit Assessment
Submit Assessment
Should be Empty: