Bridget Ingle

Medical History for Orofacial Myology Consultation

The following questions are only for Orofacial Myology appointments. Please be brief.

Please complete the below medical history information ONLY IF REQUESTED TO DO SO as soon as you have made a booking or at least 24 hours prior to your appointment.

* = mandatory response required

Please correct the following errors before submitting the form again.

Appointment date with Bridget

THIS INFORMATION IS ABOUT YOUR CHILD:

Name

Date of birth

Medical conditions

Medicines

Any surgeries

Any medical situations with mother or child during the pregnancy with this child

Weeks gestation at birth

Notable birth issues

Baby breastfeeding/feeding summary

Solid food eating issues

Drinking issues

Sleeping issues

Snoring

Mouth breathing

Dental issues

ENT investigations

Sucking/chewing habits

Behaviour and concentration

Other

Parent name

Parent mobile number

Parent email address