Feeding Form

First Name:

Last Name:

Goes by:

DOB:

Gender

Male Female

Name of Parent/ Guardian completing this form:

Father’s/Caregiver’s Name:

Relationship To Child

Biological

Adoptive

Step

Foster

Other

Mother's/Caregiver's Name:

Relationship To Child

Biological

Adoptive

Step

Foster

Other

Predominant Language Spoken at Home:

Client lives with:

Both Parents

Mother

Father

Other

Any Siblings

Yes

Is there any history of feeding, speech, language, hearing, motor, or sensory problems in other family members?

Yes

If Yes, please describe

School or daycare currently attending

Services your child receives at school

Are there any academic and/or behavioral difficulties reported? By whom? Please describe:

Vaginal

C-section

Multiple births

Complications during delivery

Please list all birth history including loss of oxygen, fetal distress, NICU stay, and any other complications during pregnancy and delivery

Frequent colds or is frequently congested.

Frequent sore throats or strep.

Pneumonia or aspiration pneumonia.

Mouth breathing

Snoring

Obstructive sleep or central apnea

Seasonal allergies

Sinusitis

Tracheostomy

Bronchomalacia, laryngomalacia, or tracheomalacia

Pressure equalization tubes

Hearing loss

Tonsillectomy or adenoidectomy

Lip or tongue ties released

Cardiac health concerns

Neoplasms

Has constipation or diarrhea problems

Failure to gain weight

Vomiting or digestion problems

Reflux/GERD

Esophagitis secondary to GERD

Dehydration

Frequent headaches

Seizures

Has/had a feeding tube (NG, J, G, Gavage)

If there are any Yes responses above, please elaborate below

List any conditions, disorders, or diseases of the Nervous/Circulatory/ Respiratory/Musculoskeletal systems:

List any congenital malformations, deformities, or chromosomal abnormalities.

Bowel Movement Information:

Allergies/ Intolerances

Detailed Family History of Allergies:

Medications (include name, dosage, reason & any negative reactions)

Hospitalizations and surgeries?

Instrumental evaluations of swallowing function? Check any that apply.

Modified Barium Swallow study (MBSS)

Videofluoroscopic Swallow study (VFSS)

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

Upper GI

pH probe

Please upload or bring a copy of any reports to your child’s evaluation.

You can select multiple files by holding down the 'Ctrl' key (Windows) or 'Command' key (Mac) while selecting.

Check all that apply

Yes

Frequently arch their back

Cry, scream

Spit up

Gag or Cough

Pull at nipple

Show signs of distress (shudder, grimace, turn away, splay fingers, etc)

Seem out of breath or noisy breathing

Latched immediately following birth

Had trouble latching at birth, but eventually figured it out

Had trouble latching at birth and breastfeeding was unsuccessful

Has/had a shallow latch

Uses/used a nipple shield to successfully breastfeed

Uses/used supplemental nursing system (SNS)

Uses/used a finger feeder

Uses/used a syringe for feeding

Bottle Feeding:
Please list any and all bottles, nipples, and/or feeding systems attempted to date:

Please add any additional information that you feel is important to share regarding breast or bottle feeding (e.g., if you worked with an IBCLC or other feeding therapist, if you needed to triple feed your baby, etc):

Ate cut up table foods/finger foods (ex: peas, rice, diced peaches):

Drank from a straw cup:

Drank from an open cup:

Used a spoon and fork independently:

Weaned from pacifier:

Weaned from sippy cup:

Thumb or finger sucking

Nail biting

Object mouthing/chewing

Clenching/grinding teeth

Extended pacifier or sippy cup use (past 12 months of age)

Excessive drooling

Food or liquid from nose

Strong food preferences (e.g., certain tastes, textures, shapes, color, or brands)

Low volume of food

Poor appetite

Had trouble transitioning between stages of food

Is a “picky” eater

Turn head/closes mouth when food approaches

My child's a noisy eater (e.g., chomps when eating)

My child's a messy eater (e.g., food falls out of mouth)

Eats no fruits

Eats no vegetables

Has difficulty chewing; may pocket food or hold onto it for long periods of time

My child takes large bites

My child takes small bites

My child needs to swallow liquid to completely clear mouth while eating

Coughs or chokes on food frequently

My child sounds gurgly after eating

Hiccups after eating

Burps during or following a meal/snack

My child complains about stomach aches

My child eats less than 10 foods

My child eats less than 20 foods

My child has difficulty brushing teeth

List the foods the client will currently eat and drink:

List any foods the client refuses:

Thin liquids (i.e. water)