Child Tongue Tie Questionnaire Name First Last Birth Date AgeMedical IssuesMedications TakingHas your child experienced any of the following issues? Please check or elaborate as needed. Speech Frustration with communication Difficult to understand by parents Difficult to understand by outsiders % Percent of time you understand your child Difficulty speaking fast Difficulty getting words out (groping for words) Stuttering Mumbling or speaking softly “Baby talk” Trouble with sounds (which?) Speech delay (when?) Speech therapy (how long?) Speech harder to understand in long sentences Trouble with soundsSpeech delaySpeech therapyFeeding Frustration when eating Difficulty transitioning to solid foods Slow eater (doesn’t finish meals) Grazes on food throughout the day Packing food in cheeks like a chipmunk Picky with textures (which?) (fill below) Choking or gagging on food Spits out food Other Picky with texturesOtherNursing or Bottle-Feeding Issues as a Baby Painful nursing or shallow latch Poor weight gain Reflux or spitting up Unable to hold pacifier Milk dribbling out of mouth Poor supply Nipple shield required for nursing Clicking or smacking noise when eating Other OtherSleep Issues Sleeps in strange positions Kicks and flails around at night Wakes easily or often Wets the bed Wakes up tired and not refreshed Grinds teeth while sleeping Sleeps with mouth open Snores while sleeping (how often) Gasps for air or stops breathing (sleep apnea) Snores while sleeping(how often)Other related issues Neck or shoulder pain or tension TMJ pain, clicking, or popping Headaches or migraines Strong gag reflex Mouth open / mouth breathing during the day Tonsils or adenoids removed previously Ear tubes previously Reflux (medicated or not) ADHD / ADD Constipation Pediatrician First Last Speech Pathologist First Last
