Feeding Intake

Date:

Child's name: Date of Birth:

Age:

Address: City:

Zip code:

Phone Number:

Email:

Father's name: Mother's name:

Dad work phone: Dad cell:

Mom work phone: Mom cell:

Alternate contact name:

Alternate contact's number:

Child lives with: Mother Father Both Parents Other

Medical Diagnoses pertinent to feeding issues: (i.e. reflux, syndromes, cleft palate, sensory processing disorder (SPD), etc. )



Is your child currently enrolled in individual feeding therapy with a speech or occupational therapist?

Yes No

If yes, for how long?

Do you feel it has helped?

• Please explain, in your own words, what your child is having difficulty with related to eating and when the feeding problems began.



• Was your child breast or bottle fed and for how long? How did your child manage either (i.e. latching, suction, etc.)?



• During these early feedings, did your child cry, arch his/her back, gag, vomit, spit up, cough, and/or fatigue easily?



• Does your child primarily use a bottle, sippy cup, straw or open cup to drink? How was the weaning or transition process?



• At what age did your child transition to:
1. baby cereal:
2. finger foods:
3. baby food:
4. table food:



• Has your child ever been fed via a tube?
Yes No



IF YOUR CHILD EATS BY MOUTH, PLEASE ANSWER THE FOLLOWING QUESTIONS:




• List the foods your child currently eats and drinks. Please italicize favorites and include specific brands.





• List the foods your child refuses.





• List the foods your child is unable to handle





• What is your child's reaction to food he/she dislikes?





• Does your child have any food allergies?





• Describe your child's mealtime experience:





• Who typically feeds your child?





• Who typically eats with your child?





• What type of chair is used?





• How long does mealtime typically last?





• Does your child use utensils?





• Does your child require coaxing to eat?





• Are there any activities going on during mealtime:

Yes No


• If yes, please describe:





• What times does your child typically eat and what types of food do they eat? (Ex. 8:00-cereal; 10:00-goldfish, etc.)





• What is your child's sleep schedule?





• Is your child sensitive to the temperature of food?


Yes No


• Does your child mind having his/her hands/face dirty or messy when eating?


Yes No

• What sensory concerns, if any, do you have for your child?






IF YOUR CHILD IS TUBE FED, PLEASE ANSWER THE FOLLOWING QUESTIONS:



• What type of formula is used and how do you mix it?





• Please detail your child's feeding schedule below:



1. Time of feeding





2. NG,G or continuous:





3. Amount




Gravity or Pump


4. How do you feel your child tolerates his tube feeding?





5. Does your child exhibit anticipation of feedings or express hunger?






ANSWER FOR ALL CHILDREN:




• Has your child ever been on any type of special diet other than what you just described? If yes, please describe type of diet and what age your child was on the diet. What reason was your child on this diet, and what was your child's response.





• Has your child lost or gained any weight in the last 6 months, and how much?





• Would you describe your childs weight as: (select one)


Ideal Underweight Overweight


• Does your child have/had any of the following problems? Dental, GERD(reflux), frequent constipation, frequent diarrhea, vomiting, choking, gagging, coughing while swallowing, excessive drooling, or short frenulum (tongue tied)





• What other evaluations have been completed regarding your child's feeding difficulties and what were the results?





• What treatments have been tried for this problem and what were the results?





• Does your child exhibit any of the following secondary behaviours? Negotiation, tantrums, manipulation, stalling, reasoning out of certian foods, etc. Please explain:





• How can we be most helpful to you and your child?