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Feeding History Form
pedconnectot
2023-12-02T08:49:46-06:00
Feeding History
Feeding Evaluation Intake
Client Name
First
Last
Parent Name
First
Last
Email
Client Date of Birth
MM slash DD slash YYYY
Client Gender
Boy
Girl
Client Medical History
Reason for Referral:
Referring Physician:
Referring Physician Phone:
Referring Physician Fax:
Has the client ever been followed by any of the following specialists? Check all that apply
Gastroenterology
Endocrine
Ear, Nose, Throat
Respiratory/Pulmonary
Orthodontics
Audiology
Ophthalmology
Other
If yes, please explain when, why, and what was addressed/monitored.
Has the client ever recevied Feeding Therapy? If yes, when and where did this occur? What skills were addressed? What treatments were provided?
Has the client ever received a swallow study? If yes, when and where did this occur? Please provide records from this procedure, if possible
Client Feeding Diagnoses
Dysphagia/Swallow Delay
Oral Motor Delay
Reflux/GERD
Eosinophilic Esophagitis (EoE)
G-Tube/GJ Tube/NG Tube
Picky Eater/Selective Eating
Does the client have any food and/or medication allergies or sensitivities? If yes, please list them:
Does the client have any special dietary requirements? If yes, please list them below:
Has the client ever been on thickener? If yes, please list what type of thickener, what consistency, and when this was required.
Client Feeding History
How was the client fed at birth? Select all that apply
Breast
Bottle
Tube
If the client was breastfed, at what age was he/she weaned?
If the client used a bottle, at what age was he/she weaned?
Did the client have difficulty feeding during the first 6 months of life? Did he/she require any additoinal support or modifications for safety and efficiency? If yes, please explain:
When were purees introduced?
Did the client have any difficulty transitioning to purees? If yes, please explain below:
When were solids introduced?
Did the client have any difficulty transitioning to solids? If yes, please explain below:
When were sippy cups introduced?
When were straw cups introduced?
When were open cups introduced?
Did the client have any difficulty transitioning to these cups? If yes, please explain below:
Did the client use a pacifier? Select one
Yes
No
Still using
Currently weaning
If the client used a pacifier, at what age was he/she weaned?
If the client is still using a pacifier, when does he/she use it?
Client's Current Feeding Behaviors
Client's Current Feeding Schedule: Please list general time of day any meal or snack is provided (i.e. 8 am breakfast, 10:30 am snack, 12 pm Lunch, etc)
Clients Current Diet
Please list all of the foods that the client regularly east in each food group.
Proteins (meat, beans, cheese, yogurt, nuts, etc)
Carbohydrates (cereal, pasta, crackers, breads, granola bars, chips, etc)
Fruits (apple, oranges, bananas, grapes, etc)
Vegetables (carrots, broccoli, peppers, cucumber, etc)
Drinks (water, milk, juice, etc)
Other (pizza, fruit snacks, ice cream, candy, etc)
What types of cups, plates, and utensils does the client currently use:
Where do meals and/or snacks typically occur? Select all that apply
Kitchen/Dining Table
Kitchen Island/Bar
Small Kid’s Table
Couch
Floor
Bedroom
Highchair
Booster Chair
Bumbo
Wheelchair
Stroller/Adaptive Stroller
Adaptive Activity Chair
Other – Please specify
What is the client's current stooling pattern? (Select all that apply)
Daily
Every other day
Once a week
Hard
Soft
Mushy
Watery
Formed
Patty
Pellets
Pain/Discomfort
Fearful/Reluctant
Other – Please specify
What are the parent's concerns and goals related to feeding?
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