Central Office

Tongue & Lip Tie Release Follow Up (Child)

Personal Information

Patient Name*

Date of Birth*

Date of Procedure*

Has your child experienced improvement or changes in any of the following issues?

INSTRUCTIONS: Please mark any previous issues that saw improvement. Anything that worsened, please write below.

Speech

Easier to communicate

Easier to understand by parents

Easier to understand by outsiders

Easier to speak fast or long sentences

Easier to get words out (not groping for words)

Easier with sounds (which?)

New words?

Talking more (or more babbling)

Less stuttering

Less mumbling or speaking softly

Less “baby talk”

Anything worsened?:

Feeding

Less frustration when eating

Easier to eat/swallow solid foods

Eating faster

Eating more food

Finishing meals better/less grazing on foods

Trying new foods

Less packing food in cheeks (like a chipmunk)

Less picky with textures (which?)

Less choking or gagging on food

Less spiting out food

Others:

Anything worsened?:

Sleep issues

Less sleeping in strange positions

Less moving around at night (less restless)

Sleeping deeper and waking less often

Less wetting the bed

Wakes up less tired and more refreshed

Less grinding teeth while sleeping

Less sleeping with mouth open

Less snoring while sleeping

Less gasping for air or stopping breathing

Anything worsened?:

Other related issues

Less neck or shoulder pain or tension

Less TMJ pain, clicking, or popping

Less headaches or migraines

Less strong gag reflex

Less mouth open/mouth breathing during the day

Less reflux

Better attention span

Less hyperactivity issues

Less constipation

Easier to brush top teeth (after lip-tie release)

More cosmetic smile (after lip-tie release)

How much change did you see from the release?

Speech: Significantly better Somewhat better No Change Somewhat worse Significantly worse No prior issues

Feeding: Significantly better Somewhat better No Change Somewhat worse Significantly worse No prior issues

Sleep: Significantly better Somewhat better No Change Somewhat worse Significantly worse No prior issues